Healthcare Provider Details

I. General information

NPI: 1609007863
Provider Name (Legal Business Name): INTERNAL MEDICINE & PEDIATRIC ASSOCIATES, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2009
Last Update Date: 12/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 MINNEQUA AVE
PUEBLO CO
81004-3733
US

IV. Provider business mailing address

PO BOX 567
PUEBLO CO
81002-0567
US

V. Phone/Fax

Practice location:
  • Phone: 719-560-4000
  • Fax:
Mailing address:
  • Phone: 719-296-5854
  • Fax: 719-542-0746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number44566
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number44566
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code282E00000X
TaxonomyLong Term Care Hospital
License Number44566
License Number StateCO

VIII. Authorized Official

Name: DR. STEVEN J SIMERVILLE
Title or Position: SOLE MBR
Credential: MD
Phone: 719-296-5854