Provider Demographics
NPI:1447518063
Name:MARK MCDONALD P.T., P.C.
Entity type:Organization
Organization Name:MARK MCDONALD P.T., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:E
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-522-7743
Mailing Address - Street 1:427 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:CO
Mailing Address - Zip Code:80751-3033
Mailing Address - Country:US
Mailing Address - Phone:970-522-7743
Mailing Address - Fax:
Practice Address - Street 1:102 W LARIMER STREET
Practice Address - Street 2:
Practice Address - City:FLEMING
Practice Address - State:CO
Practice Address - Zip Code:80725
Practice Address - Country:US
Practice Address - Phone:970-265-4878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARK MCDONALD P.T., P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP6403OtherBLUE CROSS
CO066589Medicare PIN