Provider Demographics
NPI:1902143977
Name:MINERS COLFAX MEDICAL CENTER
Entity Type:Organization
Organization Name:MINERS COLFAX MEDICAL CENTER
Other - Org Name:MCMC OUTPATIENT CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BO
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-445-3661
Mailing Address - Street 1:203 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:RATON
Mailing Address - State:NM
Mailing Address - Zip Code:87740-2012
Mailing Address - Country:US
Mailing Address - Phone:575-445-3661
Mailing Address - Fax:575-445-7737
Practice Address - Street 1:203 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-2012
Practice Address - Country:US
Practice Address - Phone:575-445-3661
Practice Address - Fax:575-445-7737
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MINERS COLFAX MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-11
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6143261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO94005139Medicaid
NM00968Medicaid
NM46946Medicaid
NM32Z307Medicare Oscar/Certification
NM2258658Medicare Oscar/Certification