Provider Demographics
NPI:1720031834
Name:MERCY REGIONAL MEDICAL CENTER OF DURANGO
Entity Type:Organization
Organization Name:MERCY REGIONAL MEDICAL CENTER OF DURANGO
Other - Org Name:FOUR CORNERS PULMONARY & CRITICAL CARE MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:A
Authorized Official - Last Name:DIGNUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-247-4311
Mailing Address - Street 1:1010 THREE SPRINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-8296
Mailing Address - Country:US
Mailing Address - Phone:970-247-4311
Mailing Address - Fax:
Practice Address - Street 1:1010 THREE SPRINGS BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-8296
Practice Address - Country:US
Practice Address - Phone:970-764-2750
Practice Address - Fax:970-764-2778
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY REGIONAL MEDICAL CENTER OF DURANGO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-18
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Single Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04015665Medicaid
CO04015665Medicaid