Provider Demographics
NPI:1770671497
Name:THE FAMILY CLINIC OF FORT COLLINS
Entity Type:Organization
Organization Name:THE FAMILY CLINIC OF FORT COLLINS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:THORSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-482-2791
Mailing Address - Street 1:1212 E ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4007
Mailing Address - Country:US
Mailing Address - Phone:970-482-2791
Mailing Address - Fax:
Practice Address - Street 1:1212 E ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-4007
Practice Address - Country:US
Practice Address - Phone:970-482-2791
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE FAMILY CLINIC OF FORT COLLINS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-10
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18564207Q00000X
CO32165207Q00000X
CO39325207Q00000X
CO39319207Q00000X
CO19796207Q00000X
CO42006207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
804441Medicare ID - Type Unspecified
CO523108Medicare PIN
CO080100381Medicare PIN
0355780001Medicare NSC
COCI1955Medicare PIN
CO62604Medicare PIN
CO526558Medicare PIN
H73226Medicare UPIN
COI03337Medicare UPIN
H72563Medicare UPIN
E21210Medicare UPIN
D23459Medicare UPIN
COP00292794Medicare PIN
CO62634Medicare ID - Type Unspecified
CO62624Medicare ID - Type Unspecified
804442Medicare ID - Type Unspecified
CO081542425Medicare PIN
COD23662Medicare UPIN