Provider Demographics
NPI:1477565380
Name:LONGS PEAK FAMILY PRACTICE, PC
Entity Type:Organization
Organization Name:LONGS PEAK FAMILY PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:I
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-772-5578
Mailing Address - Street 1:1309 SUNSET ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3215
Mailing Address - Country:US
Mailing Address - Phone:303-772-5578
Mailing Address - Fax:303-772-8207
Practice Address - Street 1:1309 SUNSET ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3215
Practice Address - Country:US
Practice Address - Phone:303-772-5578
Practice Address - Fax:303-772-8207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CS2608Medicare PIN