Provider Demographics
NPI:1629362249
Name:SUSAN F. SANDERS MD PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:SUSAN F. SANDERS MD PROFESSIONAL CORPORATION
Other - Org Name:SANDERS SKIN CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-375-1707
Mailing Address - Street 1:3649 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-4030
Mailing Address - Country:US
Mailing Address - Phone:970-375-1707
Mailing Address - Fax:970-382-9518
Practice Address - Street 1:3649 MAIN AVE
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-4030
Practice Address - Country:US
Practice Address - Phone:970-375-1707
Practice Address - Fax:970-382-9518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-31
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO28524305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
COA79631Medicare UPIN