Basic Information
| Provider Information | |||||||||
| NPI: | 1386624203 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PATHOLOGY ASSOC OF THE ROARING FORK | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2725 | ||||||||
| Address2: | |||||||||
| City: | GLENWOOD SPGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816022725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9709451443 | ||||||||
| FaxNumber: | 9709479410 | ||||||||
| Practice Location | |||||||||
| Address1: | 1906 BLAKE AVE | ||||||||
| Address2: | |||||||||
| City: | GLENWOOD SPGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816014227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9709456535 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2006 | ||||||||
| LastUpdateDate: | 10/12/2007 | ||||||||
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| AuthorizedOfficialLastName: | STEINBRECHER | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT PATHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 9709456535 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | PA636752 | 01 | BLUE CROSS | OTHER | 04020681 | 05 | CO | MEDICAID |