Basic Information
| Provider Information | |||||||||
| NPI: | 1003859836 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PINEY CREEK MEDICAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3464 S WILLOW ST | ||||||||
| Address2: | SUITE 198 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802314531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037552900 | ||||||||
| FaxNumber: | 3037550404 | ||||||||
| Practice Location | |||||||||
| Address1: | 16728 E SMOKY HILL RD | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800152400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037661006 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 10/31/2007 | ||||||||
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| AuthorizedOfficialLastName: | RATLIFF | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3037661006 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 29331285 | 05 | CO | MEDICAID | CG0427 | 01 | CO | RAILROAD MEDICARE | OTHER | PI41532 | 01 | CO | BLUE SHIELD | OTHER |