Provider Demographics
NPI:1063567402
Name:NORTHERN COLORADO SURGICAL ASSOCIATES PC
Entity type:Organization
Organization Name:NORTHERN COLORADO SURGICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF MEDICINE
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:CHIAVETTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-482-6456
Mailing Address - Street 1:2121 E HARMONY RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3400
Mailing Address - Country:US
Mailing Address - Phone:970-482-6456
Mailing Address - Fax:970-482-3921
Practice Address - Street 1:2121 E HARMONY RD
Practice Address - Street 2:SUITE 250
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3400
Practice Address - Country:US
Practice Address - Phone:970-482-6456
Practice Address - Fax:970-482-3921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04022083Medicaid
COC2208Medicare ID - Type Unspecified