Provider Demographics
NPI:1386728640
Name:MOUNTAIN MEDICAL CENTER OF BUENA VISTA, PC
Entity type:Organization
Organization Name:MOUNTAIN MEDICAL CENTER OF BUENA VISTA, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-395-8632
Mailing Address - Street 1:PO BOX 3129
Mailing Address - Street 2:
Mailing Address - City:BUENA VISTA
Mailing Address - State:CO
Mailing Address - Zip Code:81211-3129
Mailing Address - Country:US
Mailing Address - Phone:719-395-8632
Mailing Address - Fax:719-395-4971
Practice Address - Street 1:36 OAK STREET
Practice Address - Street 2:
Practice Address - City:BUENA VISTA
Practice Address - State:CO
Practice Address - Zip Code:81211
Practice Address - Country:US
Practice Address - Phone:719-395-8632
Practice Address - Fax:719-395-4971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05638739Medicaid
DF7744OtherRAILROAD MEDICARE
CO04010187Medicaid
CO04010187Medicaid
DF7744OtherRAILROAD MEDICARE