MEDICARE: DR. SAMANTHA FAY GHISELLI 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	207ND0101X	MOHS-Micrographic Surgery Physician	A85337	CA
2	207ND0900X	Dermatopathology Physician	A85337	CA
3	207NS0135X	Procedural Dermatology Physician	A85337	CA
4	207ND0101X	MOHS-Micrographic Surgery Physician	51663	CO

General Provider Information

NPI Number	:	1942212857
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMANTHA FAY GHISELLI M.D.

Provider Business Mailing Address
First Line	:	501 S CHERRY ST STE 310
Second Line	:
City	:	GLENDALE
State	:	CO
Zip	:	80246-1322
Country	:	US
Telephone Number	:	303-333-7873
Fax Number	:	303-321-7873

Provider Business Practice Location Address
First Line	:	501 S CHERRY ST STE 310
Second Line	:
City	:	GLENDALE
State	:	CO
Zip	:	80246-1322
Country	:	US
Telephone Number	:	303-333-7873
Fax Number	:	303-321-7873

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

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	01/11/2019

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