Provider Demographics
NPI:1376682740
Name:BRECKENRIDGE MEDICAL CLINIC, LLC
Entity type:Organization
Organization Name:BRECKENRIDGE MEDICAL CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:CHODOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-668-2852
Mailing Address - Street 1:DEPARTMENT 1965
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-1965
Mailing Address - Country:US
Mailing Address - Phone:303-486-5500
Mailing Address - Fax:303-486-5501
Practice Address - Street 1:555 SOUTH PARK AVENUE
Practice Address - Street 2:PLAZA 2
Practice Address - City:BRECKENRIDGE
Practice Address - State:CO
Practice Address - Zip Code:80424
Practice Address - Country:US
Practice Address - Phone:970-453-1010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC808784Medicare PIN