Provider Demographics
NPI:1356494249
Name:ALPINE MEDICAL GROUP OF THE ROARING FORK VALLEY
Entity type:Organization
Organization Name:ALPINE MEDICAL GROUP OF THE ROARING FORK VALLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHILDREE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-927-6101
Mailing Address - Street 1:1450 E VALLEY RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BASALT
Mailing Address - State:CO
Mailing Address - Zip Code:81621-8304
Mailing Address - Country:US
Mailing Address - Phone:970-927-6101
Mailing Address - Fax:970-927-6888
Practice Address - Street 1:1450 E VALLEY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:BASALT
Practice Address - State:CO
Practice Address - Zip Code:81621-8304
Practice Address - Country:US
Practice Address - Phone:970-927-6101
Practice Address - Fax:970-927-6888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO52427277Medicaid
CO52427277Medicaid