Provider Demographics
NPI:1346384369
Name:PETER GROTUSS MD PC
Entity Type:Organization
Organization Name:PETER GROTUSS MD PC
Other - Org Name:ROARING FORK DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIAN
Authorized Official - Middle Name:RAMSEY
Authorized Official - Last Name:MELLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-927-4731
Mailing Address - Street 1:PO BOX 1489
Mailing Address - Street 2:
Mailing Address - City:BASALT
Mailing Address - State:CO
Mailing Address - Zip Code:81621-1489
Mailing Address - Country:US
Mailing Address - Phone:970-927-4731
Mailing Address - Fax:970-927-4420
Practice Address - Street 1:23262 TWO RIVERS RD
Practice Address - Street 2:
Practice Address - City:BASALT
Practice Address - State:CO
Practice Address - Zip Code:81621-9227
Practice Address - Country:US
Practice Address - Phone:970-927-4731
Practice Address - Fax:970-927-4420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20541207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COA260-8Medicare ID - Type Unspecified
COE34653Medicare UPIN
COD60642Medicare UPIN