Provider Demographics
NPI:1245318757
Name:CORTEZ MEDICAL CLINIC INC
Entity type:Organization
Organization Name:CORTEZ MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-565-8556
Mailing Address - Street 1:33 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-3105
Mailing Address - Country:US
Mailing Address - Phone:970-565-8556
Mailing Address - Fax:970-564-1134
Practice Address - Street 1:33 N ELM ST
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-3105
Practice Address - Country:US
Practice Address - Phone:970-565-8556
Practice Address - Fax:970-564-1134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30414207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04913042Medicaid
CO04913042Medicaid