Provider Demographics
NPI:1568438653
Name:LALLY, THOMAS J (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:LALLY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:10900 W 44TH AVE UNIT 200
Mailing Address - Street 2:SUITE 202
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-2742
Mailing Address - Country:US
Mailing Address - Phone:303-379-9371
Mailing Address - Fax:303-284-4082
Practice Address - Street 1:10900 W 44TH AVE UNIT 200
Practice Address - Street 2:SUITE 202
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-2742
Practice Address - Country:US
Practice Address - Phone:303-379-9371
Practice Address - Fax:303-284-4082
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO41971207P00000X
CODR.0041971207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO16108272Medicaid
COC526618OtherMEDICARE PTAN
CO16108272Medicaid