Provider Demographics
NPI:1922157874
Name:ABC FAMILY MEDICAL CARE
Entity Type:Organization
Organization Name:ABC FAMILY MEDICAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:WALDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-634-4746
Mailing Address - Street 1:125 SWOPE AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-5832
Mailing Address - Country:US
Mailing Address - Phone:719-634-4746
Mailing Address - Fax:719-634-5024
Practice Address - Street 1:125 SWOPE AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5832
Practice Address - Country:US
Practice Address - Phone:719-634-4746
Practice Address - Fax:719-634-5024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40634207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO77389573Medicaid
CO801675Medicare ID - Type Unspecified
COC23055Medicare UPIN