Provider Demographics
NPI:1609888650
Name:DERKASH PROFESSIONAL, LLC
Entity Type:Organization
Organization Name:DERKASH PROFESSIONAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:DERKASH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-945-9702
Mailing Address - Street 1:10918 COUNTY ROAD 245
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:CO
Mailing Address - Zip Code:81647-9410
Mailing Address - Country:US
Mailing Address - Phone:970-984-0615
Mailing Address - Fax:
Practice Address - Street 1:1906 BLAKE AVE
Practice Address - Street 2:
Practice Address - City:GLENWOOD SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81601-4298
Practice Address - Country:US
Practice Address - Phone:970-945-8683
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO22420174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC24861Medicare PIN