Provider Demographics
NPI:1841238250
Name:GRAND JUNCTION GASTROENTEROLOGY, PLLC
Entity Type:Organization
Organization Name:GRAND JUNCTION GASTROENTEROLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-257-6902
Mailing Address - Street 1:1035 WELLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-8122
Mailing Address - Country:US
Mailing Address - Phone:970-242-6600
Mailing Address - Fax:970-242-1070
Practice Address - Street 1:1035 WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-8122
Practice Address - Country:US
Practice Address - Phone:970-242-6600
Practice Address - Fax:970-241-8443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP00001798OtherRRPTAN
COP00403557OtherRRPTAN
CO01303684Medicaid
CO93503300Medicaid
CO35129549Medicaid
COCK9301OtherRRPTAN
CO01342740Medicaid
CO68804059Medicaid
COP00658273OtherRRPTAN
COP00001800OtherRRPTAN
CO35129549Medicaid
COCOAAA2643Medicare PIN
CO93503300Medicaid
COCOAAA4297Medicare PIN
COCO301237Medicare PIN
COCOAAA2166Medicare PIN
CO01303684Medicaid