1417993916 NPI number — POUDRE VALLEY INTERNISTS PC

Table of content: (NPI 1417993916)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417993916 NPI number — POUDRE VALLEY INTERNISTS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POUDRE VALLEY INTERNISTS 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'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:
1417993916
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4674 SNOW MESA DR
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
FORT COLLINS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80528-8615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-482-3712
Provider Business Mailing Address Fax Number:
970-482-4057

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4674 SNOW MESA DR
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
FORT COLLINS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80528-8615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-482-3712
Provider Business Practice Location Address Fax Number:
970-482-4057
Provider Enumeration Date:
06/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCCANN-STOECKLE
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
970-482-3712

Provider Taxonomy Codes

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

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

  • Identifier: 06D0911568 . This is a "CLIA" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 10025031400 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 117631500 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05675839 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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