Provider Demographics
NPI:1437690302
Name:COMMUNITY MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:COMMUNITY MEDICAL GROUP, LLC
Other - Org Name:GRAND VALLEY WOMEN'S HEALTH SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-644-3011
Mailing Address - Street 1:PO BOX 1727
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81502-1727
Mailing Address - Country:US
Mailing Address - Phone:970-263-3190
Mailing Address - Fax:
Practice Address - Street 1:688 23 1/2 ROAD
Practice Address - Street 2:SUITE 304
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-8904
Practice Address - Country:US
Practice Address - Phone:970-644-3190
Practice Address - Fax:970-644-3965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-13
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000151916Medicaid