MEDICARE: THE PAGOSA MEDICAL GROUP LLC

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	208600000X	Surgery Physician

General Provider Information

NPI Number	:	1255857660
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE PAGOSA MEDICAL GROUP LLC

Provider Business Mailing Address
First Line	:	27B TALISMAN DR UNIT 3
Second Line	:
City	:	PAGOSA SPGS
State	:	CO
Zip	:	81147-7914
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	27B TALISMAN DR UNIT 3
Second Line	:
City	:	PAGOSA SPGS
State	:	CO
Zip	:	81147-8114
Country	:	US
Telephone Number	:	970-372-0456
Fax Number	:	888-974-3247

Authorized Official
Title or Position	:	COMMUNICATION DIRECTOR
Name	:	MICHELLE GRIEGO
Credential	:
Telephone Number	:	970-372-0456

Provider Enumeration Date	:	08/17/2017
Last Update Date	:	08/17/2017

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