Healthcare Provider Details

I. General information

NPI: 1770537490
Provider Name (Legal Business Name): PHC-FORT MORGAN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 09/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 LINCOLN ST
FORT MORGAN CO
80701-3210
US

IV. Provider business mailing address

1000 LINCOLN ST CS4200
FORT MORGAN CO
80701-3210
US

V. Phone/Fax

Practice location:
  • Phone: 970-867-3391
  • Fax: 970-542-3306
Mailing address:
  • Phone: 970-867-3391
  • Fax: 970-542-3306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM M. GRACEY
Title or Position: COO
Credential:
Phone: 615-372-8500