Basic Information
| Provider Information | |||||||||
| NPI: | 1265452817 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KINNICK | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 WELLINGTON AVE STE 206 | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815016131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702437245 | ||||||||
| FaxNumber: | 9702411308 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120 WELLINGTON AVE | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815016129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702437245 | ||||||||
| FaxNumber: | 9702411308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 06/14/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | DR.0044198 | CO | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 55230059 | 05 | CO | MEDICAID | P00366838 | 01 | RAILROAD MEDICARE | OTHER | T0514 | 05 | UT | MEDICAID |