1710941158 NPI number — MOUNTAIN STATES PATHOLOGY PC

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710941158 NPI number — MOUNTAIN STATES PATHOLOGY PC

Employer Identification Number (EIN):

Provider Organization Name:

MOUNTAIN STATES PATHOLOGY 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 Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

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Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1710941158

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

12/17/2007

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 744127

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

DALLAS

Provider Business Mailing Address State Name:

TX

Provider Business Mailing Address Postal Code:

75374

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

719-776-5816

Provider Business Mailing Address Fax Number:

719-776-2108

Provider First Line Business Practice Location Address:

2222 N NEVADA AVE

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

COLORADO SPRINGS

Provider Business Practice Location Address State Name:

CO

Provider Business Practice Location Address Postal Code:

80907

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

719-776-5000

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

04/13/2006

Authorized Official Last Name:

FRANQUEMONT

Authorized Official First Name:

DOUGLAS

Authorized Official Middle Name:

WILLIAM

Authorized Official Title or Position:

PRESIDENT

Authorized Official Telephone Number:

719-776-5816

• Taxonomy code: 207ZC0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207ZD0900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207ZH0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207ZM0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 12174823 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
• Identifier: 25157329 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
• Identifier: 806943705 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
• Identifier: 119630800 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
• Identifier: 806943700 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
• Identifier: 806943703 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
• Identifier: 04020889 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
• Identifier: 806943702 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
• Identifier: 806943704 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
• Identifier: 04978722 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
• Identifier: 66282829 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".