Provider Demographics
NPI:1013114230
Name:FRONT RANGE OTOLARYNGOLOGY & FACIAL PLASTIC SURGERY PC
Entity Type:Organization
Organization Name:FRONT RANGE OTOLARYNGOLOGY & FACIAL PLASTIC SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MD
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:CAVANAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:720-494-9111
Mailing Address - Street 1:1325 DRY CREEK DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-7731
Mailing Address - Country:US
Mailing Address - Phone:720-494-9111
Mailing Address - Fax:720-494-9555
Practice Address - Street 1:1325 DRY CREEK DR
Practice Address - Street 2:SUITE 103
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-7731
Practice Address - Country:US
Practice Address - Phone:720-494-9111
Practice Address - Fax:720-494-9555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO207YS0123X174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO91282888Medicaid
CO94320381Medicaid
CO1013114230Medicare PIN
COH43078Medicare UPIN