Provider Demographics
NPI:1326451105
Name:MT CARMEL PRIMARY CARE
Entity Type:Organization
Organization Name:MT CARMEL PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:HERDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-386-2727
Mailing Address - Street 1:911 ROBINSON AVE
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CO
Mailing Address - Zip Code:81082-2811
Mailing Address - Country:US
Mailing Address - Phone:719-845-4800
Mailing Address - Fax:866-712-1013
Practice Address - Street 1:911 ROBINSON AVE
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-2811
Practice Address - Country:US
Practice Address - Phone:719-845-4800
Practice Address - Fax:866-712-1013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-09
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30427261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO81030258Medicaid
CO81030258Medicaid