1508078759 NPI number — BROOKE M HALLIWELL DO

Table of content: BROOKE M HALLIWELL DO (NPI 1508078759)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508078759 NPI number — BROOKE M HALLIWELL DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HALLIWELL
Provider First Name:
BROOKE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BENGTSON
Provider Other First Name:
BROOKE
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.O.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508078759
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/31/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1830 BLAKE AVENUE
Provider Second Line Business Mailing Address:
SUITE 208
Provider Business Mailing Address City Name:
GLENWOOD SPGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81601-4592
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-945-2238
Provider Business Mailing Address Fax Number:
970-928-8926

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1830 BLAKE AVENUE
Provider Second Line Business Practice Location Address:
SUITE 208
Provider Business Practice Location Address City Name:
GLENWOOD SPGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81601-4592
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-945-2238
Provider Business Practice Location Address Fax Number:
970-928-8926
Provider Enumeration Date:
05/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  OT012106 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 49947 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 49947 . This is a "LICENSE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 1508078759 . This is a "NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 61273546 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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