Provider Demographics
NPI:1881725844
Name:INTERNAL MEDICINE CLINIC INC.
Entity type:Organization
Organization Name:INTERNAL MEDICINE CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMIN
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:GOOSSENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-224-9508
Mailing Address - Street 1:2021 BATTLECREEK DR UNIT B
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-5120
Mailing Address - Country:US
Mailing Address - Phone:970-224-9508
Mailing Address - Fax:970-999-3428
Practice Address - Street 1:2021 BATTLECREEK DR UNIT B
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-5120
Practice Address - Country:US
Practice Address - Phone:970-224-9508
Practice Address - Fax:970-993-4289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12-06712174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04014205Medicaid
COCK4008Medicare PIN