Provider Demographics
| NPI: | 1720011786 |
|---|---|
| Name: | BIG THOMPSON MEDICAL GROUP INC |
| Entity type: | Organization |
| Organization Name: | BIG THOMPSON MEDICAL GROUP INC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | PRESIDENT |
| Authorized Official - Prefix: | DR |
| Authorized Official - First Name: | EDWARD |
| Authorized Official - Middle Name: | A |
| Authorized Official - Last Name: | NORMAN |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | MD |
| Authorized Official - Phone: | 970-663-0135 |
| Mailing Address - Street 1: | 1627 E 18TH ST |
| Mailing Address - Street 2: | |
| Mailing Address - City: | LOVELAND |
| Mailing Address - State: | CO |
| Mailing Address - Zip Code: | 80538-4209 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 970-663-0135 |
| Mailing Address - Fax: | 970-461-1422 |
| Practice Address - Street 1: | 1627 E 18TH ST |
| Practice Address - Street 2: | |
| Practice Address - City: | LOVELAND |
| Practice Address - State: | CO |
| Practice Address - Zip Code: | 80538-4209 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 970-663-0135 |
| Practice Address - Fax: | 970-461-1422 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-07-09 |
| Last Update Date: | 2011-01-06 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| CO | 19473 | 207Q00000X |
| CO | 37927 | 207R00000X |
| CO | 18320 | 207RA0201X |
| CO | 33354 | 207V00000X |
| CO | 31069 | 208000000X |
| CO | 48281 | 2084N0400X |
| CO | 37823 | 208M00000X |
| CO | 27598 | 261QU0200X |
| CO | 2059 | 363A00000X |
| CO | 89947 | 363L00000X |
| CO | 61438 | 367A00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207RA0201X | Allopathic & Osteopathic Physicians | Internal Medicine | Allergy & Immunology | Group - Multi-Specialty |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
| No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty | |
| No | 261QU0200X | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | Group - Multi-Specialty |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
| No | 367A00000X | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| CO | 61238864 | Medicaid | |
| CO | 69579725 | Medicaid | |
| CO | 97728756 | Medicaid | |
| CO | 98471881 | Medicaid | |
| CO | 40757820 | Medicaid | |
| CO | 12408221 | Medicaid | |
| CO | 04117040 | Medicaid | |
| CO | 41736028 | Medicaid | |
| CO | 49422839 | Medicaid | |
| CO | 10374523 | Medicaid | |
| CO | 43222820 | Medicaid | |
| CO | 71131523 | Medicaid | |
| CO | 04657045 | Medicaid | |
| CO | 04005062 | Medicaid | |
| CO | 17223822 | Medicaid | |
| CO | 71131523 | Medicaid | |
| NE | 099867 | Medicare PIN |
