MEDICARE: EAGLE RIDGE MEDICAL INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician

General Provider Information

NPI Number	:	1073033163
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAGLE RIDGE MEDICAL INC

Provider Business Mailing Address
First Line	:	1606 PRAIRIE CENTER PKWY STE 350
Second Line	:
City	:	BRIGHTON
State	:	CO
Zip	:	80601-4005
Country	:	US
Telephone Number	:	303-498-3440
Fax Number	:	303-498-3445

Provider Business Practice Location Address
First Line	:	1606 PRAIRIE CENTER PKWY STE 350
Second Line	:
City	:	BRIGHTON
State	:	CO
Zip	:	80601-4005
Country	:	US
Telephone Number	:	303-498-3440
Fax Number	:	303-498-3445

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	JENNIFER BUCHLOH
Credential	:
Telephone Number	:	303-498-3440

Provider Enumeration Date	:	06/21/2017
Last Update Date	:	07/21/2022

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