Provider Demographics
NPI:1720283914
Name:SURGICAL CLINIC OF GREELEY, PC
Entity type:Organization
Organization Name:SURGICAL CLINIC OF GREELEY, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:S
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-350-0948
Mailing Address - Street 1:6801 W. 20TH ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634
Mailing Address - Country:US
Mailing Address - Phone:970-350-0948
Mailing Address - Fax:970-350-0952
Practice Address - Street 1:6801 W. 20TH ST
Practice Address - Street 2:SUITE 202
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634
Practice Address - Country:US
Practice Address - Phone:970-350-0948
Practice Address - Fax:970-350-0952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20001105826174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC425108Medicare ID - Type Unspecified