Provider Demographics
NPI:1134368392
Name:MOUNTAIN SURGICAL ASSOCIATES PC, LLC
Entity type:Organization
Organization Name:MOUNTAIN SURGICAL ASSOCIATES PC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:VETRI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-799-1840
Mailing Address - Street 1:10 TOWN PLZ
Mailing Address - Street 2:SUITE 81
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-5104
Mailing Address - Country:US
Mailing Address - Phone:970-799-1840
Mailing Address - Fax:970-385-4350
Practice Address - Street 1:10 TOWN PLZ
Practice Address - Street 2:SUITE 81
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5104
Practice Address - Country:US
Practice Address - Phone:970-799-1840
Practice Address - Fax:970-385-4350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-11
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA1741363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPA1741OtherCOLORADO MEDICAL LICENSE