Provider Demographics
NPI:1235310285
Name:STONEY MESA FAMILY PRACTICE INC
Entity Type:Organization
Organization Name:STONEY MESA FAMILY PRACTICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:PURVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-874-5061
Mailing Address - Street 1:PO BOX 1129
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:CO
Mailing Address - Zip Code:81416-1129
Mailing Address - Country:US
Mailing Address - Phone:970-874-2470
Mailing Address - Fax:970-874-2475
Practice Address - Street 1:1722 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-2810
Practice Address - Country:US
Practice Address - Phone:970-874-5061
Practice Address - Fax:970-874-5074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39111207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO83777865Medicaid
COST802592OtherBCBS
COST802592OtherBCBS
CO83777865Medicaid