Provider Demographics
NPI:1770892085
Name:PHYSICAL MEDICINE CENTER OF THE ROCKIES, PLLC
Entity type:Organization
Organization Name:PHYSICAL MEDICINE CENTER OF THE ROCKIES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:FARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:970-226-1117
Mailing Address - Street 1:2244 E HARMONY RD STE 110
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3412
Mailing Address - Country:US
Mailing Address - Phone:970-226-1117
Mailing Address - Fax:970-226-0251
Practice Address - Street 1:2244 E HARMONY RD STE 110
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3412
Practice Address - Country:US
Practice Address - Phone:970-226-1117
Practice Address - Fax:970-226-0251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-04
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCHR-5953111NR0400X
COCHR-5887111NR0400X
CO49380208D00000X
CO990425363LF0000X
CONP990032363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1225155047Medicare PIN
CO1194089425Medicare PIN
CO1992739890Medicare PIN
CO1215137351Medicare PIN
FL1033315213Medicare PIN