Healthcare Provider Details

I. General information

NPI: 1427191501
Provider Name (Legal Business Name): GLENWOOD MEDICAL ASSOC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 12/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 BLAKE AVE
GLENWOOD SPRINGS CO
81601
US

IV. Provider business mailing address

1830 BLAKE AVE
GLENWOOD SPRINGS CO
81601
US

V. Phone/Fax

Practice location:
  • Phone: 970-945-8503
  • Fax: 970-945-0253
Mailing address:
  • Phone: 970-945-8503
  • Fax: 970-945-0253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LIONEL MONTOYA
Title or Position: CFO
Credential:
Phone: 970-945-8503