Provider Demographics
NPI:1629260237
Name:ASPEN LEAF INTERNAL MEDICINE, P.C.
Entity Type:Organization
Organization Name:ASPEN LEAF INTERNAL MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-242-4145
Mailing Address - Street 1:751 HORIZON CT STE 202
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-8718
Mailing Address - Country:US
Mailing Address - Phone:970-242-4145
Mailing Address - Fax:970-242-4134
Practice Address - Street 1:751 HORIZON CT STE 202
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-8718
Practice Address - Country:US
Practice Address - Phone:970-242-4145
Practice Address - Fax:970-242-4134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO37446207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO49959549Medicaid
COF41263Medicare UPIN
CO477798Medicare PIN