Basic Information
| Provider Information | |||||||||
| NPI: | 1386705978 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAST PHILLIPS COUNTY HOSPITAL DISTRICT | ||||||||
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| OtherOrganizationName: | FAMILY PRACTICE OF HOLYOKE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 E JOHNSON ST | ||||||||
| Address2: | |||||||||
| City: | HOLYOKE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 807341854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708542500 | ||||||||
| FaxNumber: | 9708543440 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 E. JOHNSON STREET | ||||||||
| Address2: | |||||||||
| City: | HOLYOKE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 807341500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708542500 | ||||||||
| FaxNumber: | 9708543440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 08/02/2019 | ||||||||
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| AuthorizedOfficialLastName: | WAS | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9708542241 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EAST PHILLIPS COUNTY HOSPITAL DISTRICT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QE0002X | Y | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care |
ID Information
| ID | Type | State | Issuer | Description | FA231008 | 01 | CO | BCBS PROV NO | OTHER | 04009916 | 05 | CO | MEDICAID |