Provider Demographics
NPI:1790053213
Name:MOUNTAIN DERMATOLOGY SPECIALISTS, PC
Entity Type:Organization
Organization Name:MOUNTAIN DERMATOLOGY SPECIALISTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:URQUHART
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-926-1800
Mailing Address - Street 1:PO BOX 2606
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-2606
Mailing Address - Country:US
Mailing Address - Phone:970-926-1800
Mailing Address - Fax:888-505-2650
Practice Address - Street 1:105 EDWARDS VILLAGE BOULEVARD
Practice Address - Street 2:SUITE G211
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632-3211
Practice Address - Country:US
Practice Address - Phone:970-926-1800
Practice Address - Fax:888-505-2650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-12
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO38262207N00000X, 207ND0900X
CO207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO60738740Medicaid
CO801705Medicare PIN
I28314Medicare UPIN