Provider Demographics
NPI:1790971679
Name:MAC WYMAN MD PC
Entity Type:Organization
Organization Name:MAC WYMAN MD PC
Other - Org Name:EDWIN M WYMAN, MD, PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:A
Authorized Official - Last Name:ARCHULETA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-565-9500
Mailing Address - Street 1:1280 N MILDRED RD STE 1
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-2212
Mailing Address - Country:US
Mailing Address - Phone:970-565-9500
Mailing Address - Fax:970-565-9538
Practice Address - Street 1:1280 N MILDRED RD STE 1
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-2212
Practice Address - Country:US
Practice Address - Phone:970-565-9500
Practice Address - Fax:970-565-9538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31702207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COF28043Medicare UPIN
CO474998Medicare PIN
CO4596600001Medicare NSC