Provider Demographics
NPI:1720084635
Name:NORTHWEST FAMILY MEDICINE
Entity Type:Organization
Organization Name:NORTHWEST FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DETWILER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-425-9581
Mailing Address - Street 1:500 DISCOVERY PKWY
Mailing Address - Street 2:SUITE 150
Mailing Address - City:SUPERIOR
Mailing Address - State:CO
Mailing Address - Zip Code:80027-8639
Mailing Address - Country:US
Mailing Address - Phone:303-425-9581
Mailing Address - Fax:303-425-9259
Practice Address - Street 1:500 DISCOVERY PKWY
Practice Address - Street 2:STE 150
Practice Address - City:SUPERIOR
Practice Address - State:CO
Practice Address - Zip Code:80027-8639
Practice Address - Country:US
Practice Address - Phone:303-425-9581
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-24
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO105493261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO452068Medicare PIN