Provider Demographics
NPI:1346451473
Name:ASPEN VALLEY PEDIATRICS, PC
Entity Type:Organization
Organization Name:ASPEN VALLEY PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HARVEY
Authorized Official - Middle Name:
Authorized Official - Last Name:FAHY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-544-1300
Mailing Address - Street 1:630 E HYMAN AVENUE, SUITE 25
Mailing Address - Street 2:
Mailing Address - City:ASPEN
Mailing Address - State:CO
Mailing Address - Zip Code:81611
Mailing Address - Country:US
Mailing Address - Phone:970-544-1300
Mailing Address - Fax:970-285-1839
Practice Address - Street 1:630 E HYMAN AVENUE
Practice Address - Street 2:SUITE 25
Practice Address - City:ASPEN
Practice Address - State:CO
Practice Address - Zip Code:81611
Practice Address - Country:US
Practice Address - Phone:970-544-1300
Practice Address - Fax:970-544-1334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO19921112619208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO82027277Medicaid
CO53579054Medicaid