Provider Demographics
NPI:1922573468
Name:COMMUNITY MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:COMMUNITY MEDICAL GROUP, LLC
Other - Org Name:GRAND VALLEY INFECTIOUS DISEASE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-242-0920
Mailing Address - Street 1:PO BOX 1727
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81502-1727
Mailing Address - Country:US
Mailing Address - Phone:970-644-3820
Mailing Address - Fax:970-644-3917
Practice Address - Street 1:688 23 1/2 ROAD
Practice Address - Street 2:SUITE 303
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-8904
Practice Address - Country:US
Practice Address - Phone:970-644-3820
Practice Address - Fax:970-644-3917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-11
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000174788Medicaid