Provider Demographics
NPI:1235313693
Name:ANIMAS SURGICAL HOSPITAL, LLC
Entity Type:Organization
Organization Name:ANIMAS SURGICAL HOSPITAL, LLC
Other - Org Name:ANIMAS FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER AND AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BOYD
Authorized Official - Last Name:BALDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-234-5954
Mailing Address - Street 1:6128 S LYNCREST AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-2560
Mailing Address - Country:US
Mailing Address - Phone:888-955-0501
Mailing Address - Fax:605-274-6186
Practice Address - Street 1:575 RIVERGATE LANE
Practice Address - Street 2:#105
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301
Practice Address - Country:US
Practice Address - Phone:970-385-2344
Practice Address - Fax:405-841-9354
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANIMAS SURGICAL HOSPITAL, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-20
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0109207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO34172271Medicaid
CO34172271Medicaid