MEDICARE: SAMANTHA GHISELLI MD PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	51663	OTHER	CO	NPI

General Provider Information

NPI Number	:	1689253734
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAMANTHA GHISELLI MD PLLC

Provider Business Mailing Address
First Line	:	501 S CHERRY ST STE 310
Second Line	:
City	:	GLENDALE
State	:	CO
Zip	:	80246-1322
Country	:	US
Telephone Number	:	303-333-7873
Fax Number	:	303-321-7873

Provider Business Practice Location Address
First Line	:	501 S CHERRY ST STE 310
Second Line	:
City	:	GLENDALE
State	:	CO
Zip	:	80246-1322
Country	:	US
Telephone Number	:	303-333-7873
Fax Number	:	303-321-7873

Authorized Official
Title or Position	:	PRACTICE MANAGE
Name	:	UNCHU RING
Credential	:
Telephone Number	:	970-390-6051

Provider Enumeration Date	:	04/06/2021
Last Update Date	:	04/06/2021

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