Provider Demographics
NPI:1215027107
Name:BENDER MEDICAL GROUP INC
Entity Type:Organization
Organization Name:BENDER MEDICAL GROUP INC
Other - Org Name:MIRAMONT FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMIN
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:E
Authorized Official - Last Name:BENDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-482-0213
Mailing Address - Street 1:4674 SNOW MESA DR
Mailing Address - Street 2:STE 140
Mailing Address - City:FT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528
Mailing Address - Country:US
Mailing Address - Phone:970-482-0213
Mailing Address - Fax:970-482-9646
Practice Address - Street 1:4674 SNOW MESA DR
Practice Address - Street 2:STE 140
Practice Address - City:FT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528
Practice Address - Country:US
Practice Address - Phone:970-482-0213
Practice Address - Fax:970-482-9646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO32679207Q00000X
CO42203207Q00000X
CO45095207Q00000X
CO27536207Q00000X
CO40384207Q00000X
CO21180207Q00000X
CO31325207Q00000X
CO46447207Q00000X
CO1082363A00000X
CO905363A00000X
CO2790363A00000X
CO2589363A00000X
CONP10339363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
654282OtherBC/BS
CO19930054Medicaid