Basic Information
| Provider Information | |||||||||
| NPI: | 1205822186 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MONTROSE MEMORIAL HOSPITAL, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NUTRITION AND DIABETES BUILDING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 S 3RD ST | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814014212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702522691 | ||||||||
| FaxNumber: | 9702407723 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 S 3RD ST | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814014212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702522691 | ||||||||
| FaxNumber: | 9702407723 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2005 | ||||||||
| LastUpdateDate: | 10/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | INGRAM | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PFS DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9702522523 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 00076 | 01 | CO | ANTHEM BLUE CROSS BLUE SH | OTHER | 187651200 | 01 | FEDERAL WORKERS COMP | OTHER | 039551899 | 01 | EEOICP | OTHER | 05006002 | 05 | CO | MEDICAID |