1508058710 NPI number — JOHN F WOLZ MD PROF LLC

Table of content: (NPI 1508058710)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508058710 NPI number — JOHN F WOLZ MD PROF LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN F WOLZ MD PROF LLC
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:
COLORADO EMERGENCY SURGERY
Provider Other Organization Name Type Code:
3
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:
1508058710
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 799
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MORGAN
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80701-0799
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-867-4916
Provider Business Mailing Address Fax Number:
970-867-8659

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
625 W PLATTE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MORGAN
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80701-2669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-867-4916
Provider Business Practice Location Address Fax Number:
970-867-8659
Provider Enumeration Date:
08/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
970-867-4916

Provider Taxonomy Codes

  • Taxonomy code: 2086S0102X , with the licence number:  AW424346 , 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)





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