1639264807 NPI number — SUSAN DENISE GHANI MD

Table of content: SUSAN DENISE GHANI MD (NPI 1639264807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639264807 NPI number — SUSAN DENISE GHANI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GHANI
Provider First Name:
SUSAN
Provider Middle Name:
DENISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NEADEAU
Provider Other First Name:
SUSAN
Provider Other Middle Name:
DENISE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639264807
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
575 RIVERGATE
Provider Second Line Business Mailing Address:
SUITE 204
Provider Business Mailing Address City Name:
DURANGO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81301-7487
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-403-1340
Provider Business Mailing Address Fax Number:
970-403-1341

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
575 RIVERGATE UNIT 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DURANGO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81301-7490
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-403-1340
Provider Business Practice Location Address Fax Number:
970-403-1341
Provider Enumeration Date:
10/04/2006

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: 207R00000X , with the licence number:  42057 , 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: 75385830 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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