MEDICARE: DR. RICHARD LYLE STALLER D.O.

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	25525	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
2	38662	OTHER	CO	BCBS
3	1016326	OTHER	CO	AETNA

General Provider Information

NPI Number	:	1962469742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD LYLE STALLER D.O.

Provider Business Mailing Address
First Line	:	30940 STAGECOACH BLVD
Second Line	:	SUITE E290
City	:	EVERGREEN
State	:	CO
Zip	:	80439-7984
Country	:	US
Telephone Number	:	303-674-8153
Fax Number	:	303-674-8303

Provider Business Practice Location Address
First Line	:	30940 STAGECOACH BLVD
Second Line	:	SUITE E290
City	:	EVERGREEN
State	:	CO
Zip	:	80439-7984
Country	:	US
Telephone Number	:	303-674-8153
Fax Number	:	303-674-8303

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

Provider Enumeration Date	:	04/27/2006
Last Update Date	:	07/08/2007

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