1053603993 NPI number — CLINT B PITCHFORTH CRNA

Table of content: CLINT B PITCHFORTH CRNA (NPI 1053603993)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053603993 NPI number — CLINT B PITCHFORTH CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PITCHFORTH
Provider First Name:
CLINT
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1053603993
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DELTA
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81416-0008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-874-7681
Provider Business Mailing Address Fax Number:
970-874-6400

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1501 E 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DELTA
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81416-2815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-874-7681
Provider Business Practice Location Address Fax Number:
970-874-6400
Provider Enumeration Date:
05/11/2011

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: 367500000X , with the licence number:  CRNA-01147 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 250160 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 100093 , 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: 634497 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1053603993 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 25670875 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 69837252 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: NMAAA1472 . This is a "MEDICARE PTAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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