Provider Demographics
NPI:1790799104
Name:SOUTH ROUTT MEDICAL CENTER HEALTH SERVICE DISTRICT
Entity Type:Organization
Organization Name:SOUTH ROUTT MEDICAL CENTER HEALTH SERVICE DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:H
Authorized Official - Last Name:SMILKSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-736-8118
Mailing Address - Street 1:PO BOX 8
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:CO
Mailing Address - Zip Code:80467-0008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 MAIN STREET
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:CO
Practice Address - Zip Code:80467
Practice Address - Country:US
Practice Address - Phone:970-736-8118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO27550207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC807234Medicare PIN