Provider Demographics
NPI:1629481254
Name:RIVERGATE ORTHOPEDICS AND ANIMAS UROLOGY, PC
Entity Type:Organization
Organization Name:RIVERGATE ORTHOPEDICS AND ANIMAS UROLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/UROLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:FORREST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-247-0508
Mailing Address - Street 1:555 RIVERGATE STE B1-106
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7478
Mailing Address - Country:US
Mailing Address - Phone:970-247-0508
Mailing Address - Fax:
Practice Address - Street 1:555 RIVERGATE STE B1-106
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7478
Practice Address - Country:US
Practice Address - Phone:970-247-0508
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-11
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO41391208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1265469340Medicare UPIN