Provider Demographics
NPI:1326648254
Name:SURFACE CREEK FAMILY PRACTICE PC
Entity Type:Organization
Organization Name:SURFACE CREEK FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:PULSIPHER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:970-856-3146
Mailing Address - Street 1:255 SW 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:CEDAREDGE
Mailing Address - State:CO
Mailing Address - Zip Code:81413
Mailing Address - Country:US
Mailing Address - Phone:970-856-3146
Mailing Address - Fax:970-806-4385
Practice Address - Street 1:255 SW 8TH AVE
Practice Address - Street 2:
Practice Address - City:CEDAREDGE
Practice Address - State:CO
Practice Address - Zip Code:81413
Practice Address - Country:US
Practice Address - Phone:970-856-3146
Practice Address - Fax:970-806-4385
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SURFACE CREEK FAMILY PRACTICE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000145531Medicaid