Provider Demographics
NPI:1508041047
Name:PEDIATRIC PARTNERS OF THE SOUTHWEST
Entity Type:Organization
Organization Name:PEDIATRIC PARTNERS OF THE SOUTHWEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:CECILE
Authorized Official - Last Name:FRALEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-375-0010
Mailing Address - Street 1:575 RIVERGATE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7487
Mailing Address - Country:US
Mailing Address - Phone:970-375-0100
Mailing Address - Fax:
Practice Address - Street 1:575 RIVERGATE
Practice Address - Street 2:SUITE 109
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7487
Practice Address - Country:US
Practice Address - Phone:970-375-0100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1083717219208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01188358Medicaid