Provider Demographics
NPI:1700843752
Name:NORTHSIDE FAMILY MEDICINE, PC
Entity Type:Organization
Organization Name:NORTHSIDE FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:M
Authorized Official - Last Name:LEWAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-905-2351
Mailing Address - Street 1:11487 AMES CT
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80020-6836
Mailing Address - Country:US
Mailing Address - Phone:303-905-2351
Mailing Address - Fax:303-603-9420
Practice Address - Street 1:11487 AMES CT
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80020-6836
Practice Address - Country:US
Practice Address - Phone:303-905-2351
Practice Address - Fax:303-603-9420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO67286861Medicaid
CO67286861Medicaid