Provider Demographics
NPI:1104006840
Name:MOBILE PHYSICIAN NETWORK, LLC
Entity Type:Organization
Organization Name:MOBILE PHYSICIAN NETWORK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GENTRY
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNLOP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-400-2930
Mailing Address - Street 1:4745 S HELENA WAY
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80015-1709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4745 S HELENA WAY
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80015-1709
Practice Address - Country:US
Practice Address - Phone:303-400-2930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COE46948Medicare UPIN
COC810979Medicare PIN