Provider Demographics
NPI:1386624203
Name:PATHOLOGY ASSOC OF THE ROARING FORK
Entity type:Organization
Organization Name:PATHOLOGY ASSOC OF THE ROARING FORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:S
Authorized Official - Last Name:STEINBRECHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-945-6535
Mailing Address - Street 1:PO BOX 2725
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD SPGS
Mailing Address - State:CO
Mailing Address - Zip Code:81602-2725
Mailing Address - Country:US
Mailing Address - Phone:970-945-1443
Mailing Address - Fax:970-947-9410
Practice Address - Street 1:1906 BLAKE AVE
Practice Address - Street 2:
Practice Address - City:GLENWOOD SPGS
Practice Address - State:CO
Practice Address - Zip Code:81601-4227
Practice Address - Country:US
Practice Address - Phone:970-945-6535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-18
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA636752OtherBLUE CROSS
CO04020681Medicaid
PA636752OtherBLUE CROSS