1124344080 NPI number — CHRIS K POLSLEY PA

Table of content: CHRIS K POLSLEY PA (NPI 1124344080)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124344080 NPI number — CHRIS K POLSLEY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLSLEY
Provider First Name:
CHRIS
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
M

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:
1124344080
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/16/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 S NEVADA AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTROSE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-249-7751
Provider Business Mailing Address Fax Number:
970-249-5029

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
836 S. TOWNSEND, SUITE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTROSE
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-615-9120
Provider Business Practice Location Address Fax Number:
970-240-1139
Provider Enumeration Date:
04/15/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  2994 , 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: 521319ZV3Y . This is a "MEDICARE FOR CEDAR POINT HEALTH" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 90132360 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01705524 . This is a "RAILROAD MEDICARE FOR CEDAR POINT HEALTH" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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