Provider Demographics
NPI:1760795330
Name:MERCY REGIONAL MEDICAL CENTER OF DURANGO
Entity Type:Organization
Organization Name:MERCY REGIONAL MEDICAL CENTER OF DURANGO
Other - Org Name:MERCY DIAGNOSTIC SERVICES- AZTEC
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 1:604 S RIO GRANDE AVE
Practice Address - Street 2:
Practice Address - City:AZTEC
Practice Address - State:NM
Practice Address - Zip Code:87410-2260
Practice Address - Country:US
Practice Address - Phone:505-334-5640
Practice Address - Fax:505-334-5649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-23
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1628.1261QR0200X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC8004Medicare PIN