Provider Demographics
NPI:1710941158
Name:MOUNTAIN STATES PATHOLOGY PC
Entity Type:Organization
Organization Name:MOUNTAIN STATES PATHOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:FRANQUEMONT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-776-5816
Mailing Address - Street 1:PO BOX 744127
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75374
Mailing Address - Country:US
Mailing Address - Phone:719-776-5816
Mailing Address - Fax:719-776-2108
Practice Address - Street 1:2222 N NEVADA AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907
Practice Address - Country:US
Practice Address - Phone:719-776-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-13
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Multi-Specialty
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Multi-Specialty
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematologyGroup - Multi-Specialty
No207ZM0300XAllopathic & Osteopathic PhysiciansPathologyMedical MicrobiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO12174823Medicaid
CO25157329Medicaid
ID806943705Medicaid
WY119630800Medicaid
ID806943700Medicaid
ID806943703Medicaid
CO04020889Medicaid
ID806943702Medicaid
ID806943704Medicaid
CO04978722Medicaid
CO66282829Medicaid