Provider Demographics
NPI:1700264595
Name:ST. MARY'S FAMILY MEDICINE RESIDENCY
Entity Type:Organization
Organization Name:ST. MARY'S FAMILY MEDICINE RESIDENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPARTMENT SECRETARY
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHI
Authorized Official - Middle Name:
Authorized Official - Last Name:DECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-298-7408
Mailing Address - Street 1:2698 PATTERSON RD
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-8818
Mailing Address - Country:US
Mailing Address - Phone:970-298-7408
Mailing Address - Fax:
Practice Address - Street 1:2698 PATTERSON RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-8818
Practice Address - Country:US
Practice Address - Phone:970-298-7408
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-12
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COTL0005527261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care