Provider Demographics
NPI:1619904943
Name:FORT COLLINS SKIN CLINIC, P.C.
Entity Type:Organization
Organization Name:FORT COLLINS SKIN CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:ROBIN
Authorized Official - Last Name:BAACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-484-6303
Mailing Address - Street 1:1120 E ELIZABETH ST
Mailing Address - Street 2:SUITE G-2
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4044
Mailing Address - Country:US
Mailing Address - Phone:970-484-6303
Mailing Address - Fax:970-484-6908
Practice Address - Street 1:1120 E ELIZABETH ST
Practice Address - Street 2:SUITE G-2
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-4044
Practice Address - Country:US
Practice Address - Phone:970-484-6303
Practice Address - Fax:970-484-6908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39315207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CH9654Medicare PIN
COC433308Medicare PIN