Healthcare Provider Details

I. General information

NPI: 1376682740
Provider Name (Legal Business Name): BRECKENRIDGE MEDICAL CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 10/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 SOUTH PARK AVENUE PLAZA 2
BRECKENRIDGE CO
80424
US

IV. Provider business mailing address

DEPARTMENT 1965
DENVER CO
80291-1965
US

V. Phone/Fax

Practice location:
  • Phone: 970-453-1010
  • Fax:
Mailing address:
  • Phone: 303-486-5500
  • Fax: 303-486-5501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. PAUL CHODOWSKI
Title or Position: PRESIDENT/CEO
Credential:
Phone: 970-668-2852