Provider Demographics
NPI:1043269772
Name:LONGMONT CLINIC PC
Entity type:Organization
Organization Name:LONGMONT CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, BOARD OF DIRECTORS
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:STATHIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:720-494-3173
Mailing Address - Street 1:1925 W MOUNTAIN VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3128
Mailing Address - Country:US
Mailing Address - Phone:720-494-3173
Mailing Address - Fax:720-494-3107
Practice Address - Street 1:1925 W MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3128
Practice Address - Country:US
Practice Address - Phone:720-494-3173
Practice Address - Fax:720-494-3107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO44008OtherMEDICARE GROUP NUMBER
CO0371510001Medicare NSC