Provider Demographics
NPI:1619165958
Name:MOUNTAIN MEDICAL CENTER OF BRECKENRIDGE, PC
Entity Type:Organization
Organization Name:MOUNTAIN MEDICAL CENTER OF BRECKENRIDGE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHARI
Authorized Official - Middle Name:J
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-453-7600
Mailing Address - Street 1:PO BOX 8539
Mailing Address - Street 2:1790 B AIRPORT RD
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80424-8539
Mailing Address - Country:US
Mailing Address - Phone:970-453-7600
Mailing Address - Fax:970-453-7688
Practice Address - Street 1:1790 AIRPORT ROAD
Practice Address - Street 2:UNIT 2
Practice Address - City:BRECKENRIDGE
Practice Address - State:CO
Practice Address - Zip Code:80424-8539
Practice Address - Country:US
Practice Address - Phone:970-453-7600
Practice Address - Fax:970-453-7688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-11
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO26641261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
COD15882Medicare UPIN