Basic Information
| Provider Information | |||||||||
| NPI: | 1306295506 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GUNNISON VALLEY HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GUNNISON VALLEY URGENT CARE PRO FEES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 N TAYLOR ST | ||||||||
| Address2: | |||||||||
| City: | GUNNISON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812302296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706411456 | ||||||||
| FaxNumber: | 9706414461 | ||||||||
| Practice Location | |||||||||
| Address1: | 711 N TAYLOR ST | ||||||||
| Address2: | |||||||||
| City: | GUNNISON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812302243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706411456 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2016 | ||||||||
| LastUpdateDate: | 04/18/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VANDERVEER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9706411456 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GUNNISON VALLEY HOSPITAL | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 261QC0050X | 010909 | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Critical Access Hospital |
No ID Information.