Basic Information
Provider Information | |||||||||
NPI: | 1306496674 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DELTA COUNTY MEMORIAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DCMH T-PAC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 10100 | ||||||||
Address2: |   | ||||||||
City: | DELTA | ||||||||
State: | CO | ||||||||
PostalCode: | 814160008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9708747681 | ||||||||
FaxNumber: | 9708742227 | ||||||||
Practice Location | |||||||||
Address1: | 1501 E 3RD ST | ||||||||
Address2: |   | ||||||||
City: | DELTA | ||||||||
State: | CO | ||||||||
PostalCode: | 814162815 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9708747681 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/18/2019 | ||||||||
LastUpdateDate: | 01/23/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROEBER | ||||||||
AuthorizedOfficialFirstName: | JODY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CCO | ||||||||
AuthorizedOfficialTelephone: | 9708742256 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/23/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X |   |   | Y |   | Hospital Units | Medicare Defined Swing Bed Unit |   |
No ID Information.