Provider Demographics
NPI:1417935446
Name:DELTA COUNTY MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:DELTA COUNTY MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRACIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-399-2611
Mailing Address - Street 1:PO BOX 10100
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:CO
Mailing Address - Zip Code:81416-0008
Mailing Address - Country:US
Mailing Address - Phone:970-874-7681
Mailing Address - Fax:970-874-2227
Practice Address - Street 1:1501 E 3RD STREET
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-2815
Practice Address - Country:US
Practice Address - Phone:970-874-7681
Practice Address - Fax:970-874-2227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-09
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207PE0004X, 261QR1300X, 332B00000X
CO0338282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCD6216OtherRAILROAD MEDICARE
COCF6004OtherNORIDIAN MEDICARE
CO04825048Medicaid
CO04825048Medicaid
COCD6216OtherRAILROAD MEDICARE