Basic Information
| Provider Information | |||||||||
| NPI: | 1336124700 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREELEY MEDICAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 16TH ST | ||||||||
| Address2: | |||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806315114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703531551 | ||||||||
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| Address1: | 1900 16TH ST | ||||||||
| Address2: | |||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806315114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703531551 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2005 | ||||||||
| LastUpdateDate: | 10/14/2011 | ||||||||
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| AuthorizedOfficialLastName: | STONE | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 9703502416 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 04560082 | 05 | CO | MEDICAID |