MEDICARE: BARIATRIC AND LIFESTYLE MEDICINE LLC

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	207RB0002X	Obesity Medicine (Internal Medicine) Physician	37885	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	:	1851695985
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BARIATRIC AND LIFESTYLE MEDICINE LLC

Provider Business Mailing Address
First Line	:	1939 WILMINGTON DR
Second Line	:	SUITE 102
City	:	FORT COLLINS
State	:	CO
Zip	:	80528-6404
Country	:	US
Telephone Number	:	970-980-6024
Fax Number	:	877-489-6002

Provider Business Practice Location Address
First Line	:	1939 WILMINGTON DR
Second Line	:	SUITE 102
City	:	FORT COLLINS
State	:	CO
Zip	:	80528-6404
Country	:	US
Telephone Number	:	970-980-6024
Fax Number	:	877-489-6002

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	MELISSA J MCCANN
Credential	:
Telephone Number	:	970-980-6024

Provider Enumeration Date	:	01/04/2011
Last Update Date	:	01/04/2011

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