Provider Demographics
NPI:1952366593
Name:EASTERN PLAINS MEDICAL CLINIC OF CALHAN
Entity type:Organization
Organization Name:EASTERN PLAINS MEDICAL CLINIC OF CALHAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RENAE
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:719-347-0100
Mailing Address - Street 1:PO BOX 275
Mailing Address - Street 2:
Mailing Address - City:CALHAN
Mailing Address - State:CO
Mailing Address - Zip Code:80808-0275
Mailing Address - Country:US
Mailing Address - Phone:719-347-0100
Mailing Address - Fax:719-347-0851
Practice Address - Street 1:560 CRYSTOLA ST
Practice Address - Street 2:
Practice Address - City:CALHAN
Practice Address - State:CO
Practice Address - Zip Code:80808-8699
Practice Address - Country:US
Practice Address - Phone:719-347-0100
Practice Address - Fax:719-347-0851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03833232Medicaid
CO063858Medicare ID - Type Unspecified
CO03833232Medicaid