Healthcare Provider Details

I. General information

NPI: 1588225015
Provider Name (Legal Business Name): FORT COLLINS WOMEN'S CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 ROCKY MOUNTAIN AVE STE 2150
LOVELAND CO
80538-9004
US

IV. Provider business mailing address

1107 S LEMAY AVE STE 300
FORT COLLINS CO
80524-3955
US

V. Phone/Fax

Practice location:
  • Phone: 970-493-7442
  • Fax: 970-493-2990
Mailing address:
  • Phone: 970-493-7442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: SUSAN FREEMAN
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 970-294-4462