Provider Demographics
NPI:1720272297
Name:TRI-COUNTY MEDICAL CENTER, P.C.
Entity Type:Organization
Organization Name:TRI-COUNTY MEDICAL CENTER, P.C.
Other - Org Name:DOC SPINE FAMILY MEDICINE, P.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:SPINE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:303-828-9355
Mailing Address - Street 1:720 AUSTIN AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ERIE
Mailing Address - State:CO
Mailing Address - Zip Code:80516-2422
Mailing Address - Country:US
Mailing Address - Phone:303-828-9355
Mailing Address - Fax:303-828-4883
Practice Address - Street 1:720 AUSTIN AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:ERIE
Practice Address - State:CO
Practice Address - Zip Code:80516-2422
Practice Address - Country:US
Practice Address - Phone:303-828-9355
Practice Address - Fax:303-828-4883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO32971261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC486048Medicare PIN
F65560Medicare UPIN