Basic Information
Provider Information | |||||||||
NPI: | 1962859470 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SALIDA HOSPITAL DISTRICT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HEART OF THE ROCKIES REGIONAL MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 429 | ||||||||
Address2: |   | ||||||||
City: | SALIDA | ||||||||
State: | CO | ||||||||
PostalCode: | 812010429 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195302048 | ||||||||
FaxNumber: | 7195302055 | ||||||||
Practice Location | |||||||||
Address1: | 28374 COUNTY ROAD 317 | ||||||||
Address2: |   | ||||||||
City: | BUENA VISTA | ||||||||
State: | CO | ||||||||
PostalCode: | 812119158 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7193959048 | ||||||||
FaxNumber: | 7193959064 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/16/2016 | ||||||||
LastUpdateDate: | 05/16/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FAGERBERG | ||||||||
AuthorizedOfficialFirstName: | LESLEY | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
AuthorizedOfficialTelephone: | 7195302213 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 010628 | CO | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207XX0005X | 010628 | CO | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
No ID Information.