1073867271 NPI number — GLENWOOD MEDICAL ASSOCIATES PC

Table of content: (NPI 1073867271)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073867271 NPI number — GLENWOOD MEDICAL ASSOCIATES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLENWOOD MEDICAL ASSOCIATES PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073867271
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1830 BLAKE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENWOOD SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81601-4275
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-945-8503
Provider Business Mailing Address Fax Number:
970-945-0253

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 N HORSESHOE TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SILT
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81652-9832
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-876-5700
Provider Business Practice Location Address Fax Number:
970-876-0482
Provider Enumeration Date:
11/09/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BURNS
Authorized Official First Name:
TIM
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF ADMINISTRATIVE OFFICER
Authorized Official Telephone Number:
970-945-8503

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  48893 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 03078345 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".