Provider Demographics
NPI:1205588100
Name:PEDIATRIC PARTNERS OF THE SOUTHWEST P.C.
Entity type:Organization
Organization Name:PEDIATRIC PARTNERS OF THE SOUTHWEST P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHACKEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-375-0100
Mailing Address - Street 1:810 E 3RD ST UNIT 301
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-5760
Mailing Address - Country:US
Mailing Address - Phone:970-375-0100
Mailing Address - Fax:
Practice Address - Street 1:658 S EAST ST STE 301
Practice Address - Street 2:
Practice Address - City:BAYFIELD
Practice Address - State:CO
Practice Address - Zip Code:81122-5020
Practice Address - Country:US
Practice Address - Phone:970-375-0100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC PARTNERS OF THE SOUTHWEST P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO948843159Medicaid