Provider Demographics
NPI:1396791646
Name:FORT MORGAN MEDICAL GROUP, PC
Entity type:Organization
Organization Name:FORT MORGAN MEDICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:HEPWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-867-5681
Mailing Address - Street 1:102 W 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MORGAN
Mailing Address - State:CO
Mailing Address - Zip Code:80701-2012
Mailing Address - Country:US
Mailing Address - Phone:970-867-5681
Mailing Address - Fax:970-867-7361
Practice Address - Street 1:102 W 9TH AVE
Practice Address - Street 2:
Practice Address - City:FORT MORGAN
Practice Address - State:CO
Practice Address - Zip Code:80701-2012
Practice Address - Country:US
Practice Address - Phone:970-867-5681
Practice Address - Fax:970-867-7361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04220083Medicaid
CO04220083Medicaid