Provider Demographics
NPI:1073867271
Name:GLENWOOD MEDICAL ASSOCIATES PC
Entity Type:Organization
Organization Name:GLENWOOD MEDICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-945-8503
Mailing Address - Street 1:1830 BLAKE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601-4275
Mailing Address - Country:US
Mailing Address - Phone:970-945-8503
Mailing Address - Fax:970-945-0253
Practice Address - Street 1:2001 N HORSESHOE TRL
Practice Address - Street 2:
Practice Address - City:SILT
Practice Address - State:CO
Practice Address - Zip Code:81652-9832
Practice Address - Country:US
Practice Address - Phone:970-876-5700
Practice Address - Fax:970-876-0482
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GLENWOOD MEDICAL ASSOCIATES PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-09
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO48893207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03078345Medicaid