Provider Demographics
NPI:1164048161
Name:CROSSROADS MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:CROSSROADS MEDICAL CENTER LLC
Other - Org Name:CARL A MORTIZ JR MBR
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MORITZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:303-444-6400
Mailing Address - Street 1:2760 29TH ST.
Mailing Address - Street 2:SUITE 28
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301
Mailing Address - Country:US
Mailing Address - Phone:303-444-6400
Mailing Address - Fax:303-444-6465
Practice Address - Street 1:2760 29TH ST.
Practice Address - Street 2:SUITE 28
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301
Practice Address - Country:US
Practice Address - Phone:303-444-6400
Practice Address - Fax:303-444-6465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-25
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0126399Medicaid