Basic Information
| Provider Information | |||||||||
| NPI: | 1831547363 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOUNTAIN PEAKS FAMILY PRACTICE PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MOUNTAIN PEAKS FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 836 S TOWNSEND AVE STE A | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814014360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706159120 | ||||||||
| FaxNumber: | 9702401139 | ||||||||
| Practice Location | |||||||||
| Address1: | 836 S TOWNSEND AVE STE A | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814014360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706159120 | ||||||||
| FaxNumber: | 9702401139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2016 | ||||||||
| LastUpdateDate: | 10/24/2016 | ||||||||
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| AuthorizedOfficialLastName: | WADE | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9702166199 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 622111300 | 01 | DEPT OF LABOR: FECA, BLACK LUNG, ENERGY | OTHER | 50825330 | 05 | CO | MEDICAID | DW8070 | 01 | RAILROAD WORKERS MEDICARE PTAN | OTHER |