Provider Demographics
NPI:1790903094
Name:TELLURIDE MEDICAL CENTER-PRIMARY CARE
Entity Type:Organization
Organization Name:TELLURIDE MEDICAL CENTER-PRIMARY CARE
Other - Org Name:TMC-PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:P
Authorized Official - Last Name:REICHARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-728-3848
Mailing Address - Street 1:PO BOX 1229
Mailing Address - Street 2:
Mailing Address - City:TELLURIDE
Mailing Address - State:CO
Mailing Address - Zip Code:81435-1229
Mailing Address - Country:US
Mailing Address - Phone:970-728-3848
Mailing Address - Fax:
Practice Address - Street 1:500 W PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:TELLURIDE
Practice Address - State:CO
Practice Address - Zip Code:81435
Practice Address - Country:US
Practice Address - Phone:970-728-3848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO063840261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO063840Medicare Oscar/Certification