1265079545 NPI number — COMMUNITY MEDICAL GROUP, LLC

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 1265079545 NPI number — COMMUNITY MEDICAL GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY MEDICAL GROUP, 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:
GRAND VALLEY CARDIOLOGY
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:
1265079545
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1727
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND JUNCTION
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81502-1727
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-644-4030
Provider Business Mailing Address Fax Number:
970-644-3914

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
688 23 1/2 ROAD
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
GRAND JCT
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81505-8904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-644-4030
Provider Business Practice Location Address Fax Number:
970-644-3914
Provider Enumeration Date:
12/05/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
THOMAS
Authorized Official First Name:
CHRISTIAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
970-644-3011

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 9000190007 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".