Provider Demographics
NPI:1083675102
Name:COLORADO MOUNTAIN MEDICAL, PC
Entity Type:Organization
Organization Name:COLORADO MOUNTAIN MEDICAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:ENGLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-926-6340
Mailing Address - Street 1:PO BOX 5850
Mailing Address - Street 2:C/O CREDENTIALING - LISA KERSTIENS
Mailing Address - City:EAGLE
Mailing Address - State:CO
Mailing Address - Zip Code:81631-5850
Mailing Address - Country:US
Mailing Address - Phone:970-926-6340
Mailing Address - Fax:970-926-6348
Practice Address - Street 1:50 BUCK CREEK ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:AVON
Practice Address - State:CO
Practice Address - Zip Code:81620
Practice Address - Country:US
Practice Address - Phone:970-926-6340
Practice Address - Fax:970-926-6348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04005617Medicaid
CO04005617Medicaid