Provider Demographics
NPI:1548443039
Name:GREELEY INTERNAL MEDICINE & NEPHROLOGY
Entity type:Organization
Organization Name:GREELEY INTERNAL MEDICINE & NEPHROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAWNAE
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-304-0010
Mailing Address - Street 1:900 14TH ST
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-4622
Mailing Address - Country:US
Mailing Address - Phone:970-304-0010
Mailing Address - Fax:
Practice Address - Street 1:900 14TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-4622
Practice Address - Country:US
Practice Address - Phone:970-304-0010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31120207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO127588Medicaid
CO471078Medicare PIN