MEDICARE: SUSAN DENISE GHANI MD

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	207R00000X	Internal Medicine Physician	42057	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639264807
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN DENISE GHANI MD

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

Provider Business Practice Location Address
First Line	:	575 RIVERGATE UNIT 204
Second Line	:
City	:	DURANGO
State	:	CO
Zip	:	81301-7490
Country	:	US
Telephone Number	:	970-403-1340
Fax Number	:	970-403-1341

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

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	03/07/2023

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