Provider Demographics
NPI:1124100763
Name:PHYSIOM ASSOCIATES, PLLC
Entity type:Organization
Organization Name:PHYSIOM ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:LOCKWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-377-9555
Mailing Address - Street 1:1300 OAKRIDGE DR
Mailing Address - Street 2:#130
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-5564
Mailing Address - Country:US
Mailing Address - Phone:970-377-9555
Mailing Address - Fax:970-377-9559
Practice Address - Street 1:1300 OAKRIDGE DR
Practice Address - Street 2:#130
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-5564
Practice Address - Country:US
Practice Address - Phone:970-377-9555
Practice Address - Fax:970-377-9559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO40137724Medicaid
AZ445119Medicaid
AZ445119Medicaid