Provider Demographics
NPI:1427155845
Name:MED PEDS CLINIC OF FORT COLLINS, LLC
Entity type:Organization
Organization Name:MED PEDS CLINIC OF FORT COLLINS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-266-3650
Mailing Address - Street 1:4674 SNOW MESA DRIVE
Mailing Address - Street 2:STE 120
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528
Mailing Address - Country:US
Mailing Address - Phone:970-266-3650
Mailing Address - Fax:970-266-3660
Practice Address - Street 1:4674 SNOW MESA DRIVE
Practice Address - Street 2:STE 120
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528
Practice Address - Country:US
Practice Address - Phone:970-266-3650
Practice Address - Fax:970-266-3660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CODB0865Medicare PIN
COC435508Medicare PIN