Provider Demographics
NPI:1174605489
Name:MOUNTAINLAND PEDIATRICS PC
Entity type:Organization
Organization Name:MOUNTAINLAND PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:SPOERKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-430-0823
Mailing Address - Street 1:8889 FOX DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80260-8842
Mailing Address - Country:US
Mailing Address - Phone:303-430-0823
Mailing Address - Fax:303-426-9581
Practice Address - Street 1:8889 FOX DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80260-8842
Practice Address - Country:US
Practice Address - Phone:303-430-0823
Practice Address - Fax:303-426-9581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04008363Medicaid
CO0600672594OtherCLIA