Provider Demographics
NPI:1669535118
Name:HERITAGE FAMILY MEDICINE
Entity type:Organization
Organization Name:HERITAGE FAMILY MEDICINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:TALBOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-224-1596
Mailing Address - Street 1:1006 ROBERTSON ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524
Mailing Address - Country:US
Mailing Address - Phone:970-224-1596
Mailing Address - Fax:970-530-1919
Practice Address - Street 1:1006 ROBERTSON ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524
Practice Address - Country:US
Practice Address - Phone:970-224-1596
Practice Address - Fax:970-530-1919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363LG0600X
CO36358207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO50773241Medicaid
COH11634Medicare UPIN
CO50773241Medicaid