MEDICARE: DR. KATHLENE SUE WALLER M.D.

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	2080A0000X	Pediatric Adolescent Medicine Physician	30233	CO

General Provider Information

NPI Number	:	1023027778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATHLENE SUE WALLER M.D.

Provider Business Mailing Address
First Line	:	HARTSHORN HEALTH SERVICE
Second Line	:	COLORADO STATE UNIVERSITY
City	:	FORT COLLINS
State	:	CO
Zip	:	80523-8031
Country	:	US
Telephone Number	:	970-491-7121
Fax Number	:	970-491-0226

Provider Business Practice Location Address
First Line	:	HARTSHORN HEALTH SERVICE
Second Line	:	COLORADO STATE UNIVERSITY
City	:	FORT COLLINS
State	:	CO
Zip	:	80523-8031
Country	:	US
Telephone Number	:	970-491-7121
Fax Number	:	970-491-0226

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	07/08/2007

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