Basic Information
| Provider Information | |||||||||
| NPI: | 1407521990 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DELTA COUNTY MEMORIAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10100 | ||||||||
| Address2: | |||||||||
| City: | DELTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814160008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708747668 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1450 BURGESS ST | ||||||||
| Address2: | |||||||||
| City: | DELTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814162849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708747668 | ||||||||
| FaxNumber: | 9708740708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2021 | ||||||||
| LastUpdateDate: | 08/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | ROEBER | ||||||||
| AuthorizedOfficialFirstName: | JODY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CCO | ||||||||
| AuthorizedOfficialTelephone: | 9708742256 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DELTA COUNTY MEMORIAL HOSPITAL | ||||||||
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| NPICertificationDate: | 07/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 011145 | 01 | CO | LICENSE | OTHER |