Provider Demographics
NPI:1952414260
Name:DOLORES MEDICAL CENTER PC
Entity type:Organization
Organization Name:DOLORES MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:BURNSIDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-882-7221
Mailing Address - Street 1:PO BOX 908
Mailing Address - Street 2:
Mailing Address - City:DOLORES
Mailing Address - State:CO
Mailing Address - Zip Code:81323-0908
Mailing Address - Country:US
Mailing Address - Phone:970-882-7221
Mailing Address - Fax:970-882-4243
Practice Address - Street 1:507 CENTRAL
Practice Address - Street 2:
Practice Address - City:DOLORES
Practice Address - State:CO
Practice Address - Zip Code:81323-0908
Practice Address - Country:US
Practice Address - Phone:970-882-7221
Practice Address - Fax:970-882-4243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO32885261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO12635871Medicaid
CO063862Medicare ID - Type UnspecifiedMEDICARE A-TRAILBLAZER
CO12635871Medicaid