Provider Demographics
NPI: | 1710278700 |
---|---|
Name: | BIG THOMPSON MEDICAL GROUP INC. |
Entity Type: | Organization |
Organization Name: | BIG THOMPSON MEDICAL GROUP INC. |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | SR VP FINANCE |
Authorized Official - Prefix: | |
Authorized Official - First Name: | DENNIS |
Authorized Official - Middle Name: | E |
Authorized Official - Last Name: | DAHLEN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 602-747-4000 |
Mailing Address - Street 1: | 1441 N 12TH ST |
Mailing Address - Street 2: | |
Mailing Address - City: | PHOENIX |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 85006-2837 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2701 MADISON SQUARE DR |
Practice Address - Street 2: | |
Practice Address - City: | LOVELAND |
Practice Address - State: | CO |
Practice Address - Zip Code: | 80538-3386 |
Practice Address - Country: | US |
Practice Address - Phone: | 970-663-0722 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | BANNER HEALTH |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2011-04-25 |
Last Update Date: | 2011-05-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QM1300X | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CO | 04005062 | Medicaid |