Basic Information
Provider Information | |||||||||
NPI: | 1104871896 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MERCY REGIONAL MEDICAL CENTER OF DURANGO | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | INPATIENT PHYSICIAN SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1010 THREE SPRINGS BLVD | ||||||||
Address2: |   | ||||||||
City: | DURANGO | ||||||||
State: | CO | ||||||||
PostalCode: | 813018296 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9702474311 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1010 THREE SPRINGS BLVD | ||||||||
Address2: |   | ||||||||
City: | DURANGO | ||||||||
State: | CO | ||||||||
PostalCode: | 813018296 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9702474311 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2006 | ||||||||
LastUpdateDate: | 01/14/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DIGNUM | ||||||||
AuthorizedOfficialFirstName: | KIRK | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | CEO PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9702474311 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MERCY REGIONAL MEDICAL CENTER OF DURANGO | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 04012712 | 05 | CO |   | MEDICAID |