Basic Information
| Provider Information | |||||||||
| NPI: | 1073520375 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAST PHILLIPS COUNTY HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FAMILY PRACTICE OF HOLYOKE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 E JOHNSON STREET | ||||||||
| Address2: | |||||||||
| City: | HOLYOKE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 807341854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708542500 | ||||||||
| FaxNumber: | 9708543440 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 E JOHNSON STREET | ||||||||
| Address2: | |||||||||
| City: | HOLYOKE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 807341854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708542500 | ||||||||
| FaxNumber: | 9708543440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WORLEY | ||||||||
| AuthorizedOfficialFirstName: | STELLA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM CEO | ||||||||
| AuthorizedOfficialTelephone: | 9708542241 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EAST PHILLIPS COUNTY HOSPITAL DISTRICT | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 59725877 | 05 | CO | MEDICAID | FA231008 | 01 | CO | BC/BS PROV # | OTHER | CC8329 | 01 | CO | RR MCR # | OTHER |