=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841238250
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRAND JUNCTION GASTROENTEROLOGY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2006
-----------------------------------------------------
Last Update Date | 09/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1035 WELLINGTON AVE
-----------------------------------------------------
City | GRAND JUNCTION
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81501-8122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-242-6600
-----------------------------------------------------
Fax | 970-241-8443
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1035 WELLINGTON AVE
-----------------------------------------------------
City | GRAND JUNCTION
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81501-8122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-242-6600
-----------------------------------------------------
Fax | 970-242-1070
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE ADMINISTRATOR
-----------------------------------------------------
Name | TARA JACOBSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 970-257-6902
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------