NPIMap

Individual provider Active NPI

Ian Wallace, MD

  • Family Medicine Physician
  • Longmont, CO
National Provider Identifier
1063732758
Registry record updated Feb 27, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
DR.0052047 Issued in CO
Practice address
220 E Rogers Rd
Longmont, CO 80501-6027
Phone
(303) 697-2583
Fax
(303) 682-6419
NPI assigned
Jun 4, 2010
Last updated
Feb 27, 2023By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Feb 27, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X DR.0052047 CO Primary

Addresses

Primary practice location

220 E Rogers Rd
Longmont, CO 80501-6027

Mailing address

203 S Rollie Ave
Fort Lupton, CO 80621-1508
Phone (303) 892-6401

Other identifiers 1

IdentifierTypeStateIssuer
9000203786MedicaidCO

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CO
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20140221000274 CO Practitioner - Family Practice 3476715764 Reassigns benefits to 3 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
University of Colorado School of Medicine, Denver, 2010
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Salud Family HealthGroup PAC ID 3173433398, shared by 15 NPIs, 75 clinicians

Practice addresses (Care Compare)

220 E Rogers Rd
Longmont, CO 80501-6027
Phone (303) 776-3250

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Colonoscopy1-10
Upper gastrointestinal (GI) endoscopy for acid reflux1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Not enrolled
HHS exclusion list flag
CMS’s directory marks this NPI as on an HHS exclusion list; no matching OIG record was found. The OIG exclusions file (LEIE) holds no record for this NPI, and the directory does not say which list the flag comes from. How exclusions are shown Confirm with the OIG exclusions search.
Credentials
Doctor of Medicine

Practice roles

OrganizationSpecialtyStatusNew patients
Trinidad Area Health Association CurrentSince Aug 12, 2024 Accepting new patients
Trinidad Area Health Association Family Medicine Current Accepting new patients
Trinidad Area Health Association CurrentSince Aug 12, 2024 Accepting new patients
Salud Family Health Past Accepting new patients
Longs Peak Hospital Past Accepting new patients
Longmont United Hospital Past Accepting new patients
Salud Family Health Past Accepting new patients

Locations

410 Benedicta Ave
Trinidad, CO 81082
Phone (719) 846-8051

Interoperability endpoints

  • Direct secure messaging: ian.wallace@sfhc.eclinicaldirectplus.com

Organizations & group practices 8

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 2

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1275609600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1677456000000",
    "number": "1063732758",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "203 S ROLLIE AVE",
            "city": "FORT LUPTON",
            "state": "CO",
            "postal_code": "806211508",
            "telephone_number": "303-892-6401",
            "fax_number": "303-286-4589"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "220 E ROGERS RD",
            "city": "LONGMONT",
            "state": "CO",
            "postal_code": "805016027",
            "telephone_number": "303-697-2583",
            "fax_number": "303-682-6419"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "IAN",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2010-06-04",
        "last_updated": "2023-02-27",
        "certification_date": "2023-02-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "CO",
            "license": "DR.0052047",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "9000203786",
            "state": "CO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Longmont, CO

Sources for this page

Verify at the official NPI Registry.