Provider Demographics
NPI:1194313346
Name:FRASER PROFESSIONAL MEDICAL GROUP LLC
Entity type:Organization
Organization Name:FRASER PROFESSIONAL MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AARON
Authorized Official - Middle Name:SOOTS
Authorized Official - Last Name:FRASER
Authorized Official - Suffix:
Authorized Official - Credentials:DOL
Authorized Official - Phone:719-633-5255
Mailing Address - Street 1:77 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-8179
Mailing Address - Country:US
Mailing Address - Phone:719-633-5255
Mailing Address - Fax:719-488-6753
Practice Address - Street 1:77 3RD ST
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-8179
Practice Address - Country:US
Practice Address - Phone:719-633-5255
Practice Address - Fax:719-488-6753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-04
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FF9071844OtherDEA LICENSE