Healthcare Provider Details

I. General information

NPI: 1699740480
Provider Name (Legal Business Name): ENRICO JOHN VERSACE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 03/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 COUNTY ROAD 14 RIO GRANDE HOSPITAL
DEL NORTE CO
81132-8719
US

IV. Provider business mailing address

310 COUNTY ROAD 14 RIO GRANDE HOSPITAL
DEL NORTE CO
81132-8719
US

V. Phone/Fax

Practice location:
  • Phone: 719-657-4102
  • Fax: 719-657-4106
Mailing address:
  • Phone: 719-657-4102
  • Fax: 719-657-4106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number11019
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0053518
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number60167506
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number60167506
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: