MEDICARE: DR. DAVID A SEVERANCE 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	207Q00000X	Family Medicine Physician	36578-020	WI
2	207Q00000X	Family Medicine Physician	DR.0051889	CO

General Provider Information

NPI Number	:	1740257658
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID A SEVERANCE M.D

Provider Business Mailing Address
First Line	:	4100 E MISSISSIPPI AVE
Second Line	:
City	:	GLENDALE
State	:	CO
Zip	:	80246-3048
Country	:	US
Telephone Number	:	303-552-9522
Fax Number	:	720-729-7668

Provider Business Practice Location Address
First Line	:	4100 E MISSISSIPPI AVE
Second Line	:
City	:	GLENDALE
State	:	CO
Zip	:	80246-3048
Country	:	US
Telephone Number	:	303-552-9522
Fax Number	:	720-729-7668

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

Provider Enumeration Date	:	03/01/2006
Last Update Date	:	03/08/2016

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