MEDICARE: FT LUPTON MEDICAL TEAM PC

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	207Q00000X	Family Medicine Physician	17794	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4009915	OTHER	CO	AETNA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942382023
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FT LUPTON MEDICAL TEAM PC

Provider Business Mailing Address
First Line	:	308 DENVER AVE
Second Line	:
City	:	FORT LUPTON
State	:	CO
Zip	:	80621-1822
Country	:	US
Telephone Number	:	303-857-1007
Fax Number	:	303-857-1227

Provider Business Practice Location Address
First Line	:	308 DENVER AVE
Second Line	:
City	:	FORT LUPTON
State	:	CO
Zip	:	80621
Country	:	US
Telephone Number	:	303-857-1007
Fax Number	:	303-857-1227

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SELWYN MARTIN SPRAY
Credential	:	MD
Telephone Number	:	303-857-1007

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	06/27/2008

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Directions to “FT LUPTON MEDICAL TEAM PC ” Practice Location

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