Basic Information
| Provider Information | |||||||||
| NPI: | 1568638427 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MONTROSE REGIONAL CANCER CARE | ||||||||
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| OtherOrganizationName: | MONTROSE REGIONAL CANCER CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2233 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814013831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9707650818 | ||||||||
| FaxNumber: | 9704978410 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 S 5TH ST | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814015711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702407242 | ||||||||
| FaxNumber: | 9702407793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2008 | ||||||||
| LastUpdateDate: | 11/07/2019 | ||||||||
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| AuthorizedOfficialLastName: | INGRAM | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PFS DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9702522523 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MONTROSE MEMORIAL HOSPITAL, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 23620340 | 05 | CO | MEDICAID |