Provider Demographics
NPI:1770507428
Name:INTERNAL MEDICINE OF CANON CITY, P.C.
Entity Type:Organization
Organization Name:INTERNAL MEDICINE OF CANON CITY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:CLOWER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-275-4151
Mailing Address - Street 1:614 YALE PL
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-4611
Mailing Address - Country:US
Mailing Address - Phone:719-275-4141
Mailing Address - Fax:719-275-3743
Practice Address - Street 1:614 YALE PL
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-4611
Practice Address - Country:US
Practice Address - Phone:719-275-4141
Practice Address - Fax:719-275-3743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20545207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC397108Medicare PIN