1710206792 NPI number — ROYAL GORGE EMERGENCY MEDICINE SPECIALISTS, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710206792 NPI number — ROYAL GORGE EMERGENCY MEDICINE SPECIALISTS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROYAL GORGE EMERGENCY MEDICINE SPECIALISTS, PLLC
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:
1710206792
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1241 W MINERAL AVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
LITTLETON
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80120-5685
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-759-0854
Provider Business Mailing Address Fax Number:
303-759-0864

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1338 PHAY AVE
Provider Second Line Business Practice Location Address:
ST. THOMAS MOORE
Provider Business Practice Location Address City Name:
CANON CITY
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81212-2302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-759-0854
Provider Business Practice Location Address Fax Number:
303-759-0864
Provider Enumeration Date:
05/31/2010

Additional Information

Authorized Official

Authorized Official Last Name:
WATZ
Authorized Official First Name:
HALLET
Authorized Official Middle Name:
N.
Authorized Official Title or Position:
MD/CEO
Authorized Official Telephone Number:
303-759-0854

Provider Taxonomy Codes

  • Taxonomy code: 207PE0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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