NPIMap

Organization Active NPI

Pediatric Associates Prof LLC

  • Rural Health Clinic/Center
  • Delta, CO
National Provider Identifier
1043016124
Registry record updated Feb 20, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
PEDIATRIC ASSOCIATES PROF LLC
Practice address
242 Cottonwood St
Delta, CO 81416-4403
Phone
(970) 874-7552
Fax
(855) 638-4966
NPI assigned
Feb 20, 2025
Last updated
Feb 20, 2025By the provider in NPPES
Organization subpart
Yes
Parent organization
PEDIATRIC ASSOCIATES PROF LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 20, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Amber Hickert
Title
Practice Administrator
Phone
(970) 249-2421

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

242 Cottonwood St
Delta, CO 81416-4403

Mailing address

947 South 5TH Street
Montrose, CO 81401
Phone (970) 249-2421

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CO

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20240223002210 CO Part A Provider - Rural Health Clinic 3375592637 1 other NPI on this enrollment
Practice locations: Delta, CO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1043016124. Details of each certification follow.

Rural health clinic certification: CCN 068900

Legal name
PEDIATRIC ASSOCIATES PROF LLC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 5, 2024
Last certification
Sep 5, 2024
Ownership / control type
1C
Organization structure
PartnershipProprietary
Incorporated
Dec 1, 2004 in CO
Enrollment address
242 Cottonwood St
Ste 101
Delta, CO 81416-4404

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Etzenhouser Kei3 organizations share this tax ID, including this one
Part of
Etzenhouser Kei

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Locations

242 Cottonwood St
Delta, CO 81416
Phone (970) 249-2421

Ownership & related parties

All disclosed owners & managing parties 6

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Teal S Warthen Individual General Partnership InterestPartner Jan 1, 2015 16.66%
Thomas Miller Individual General Partnership InterestPatner Jan 1, 2021 16.66%
Miroslawa Sikorska Individual General Partnership InterestPartner Jan 1, 2022 16.66%
Romeo G Icasiano Individual General Partnership InterestPartner Dec 1, 2004 16.66%
Libuse Engelbach Individual General Partnership InterestPartner Oct 1, 2012 16.66%
Gregory P Suchon Individual General Partnership InterestManaging Partner Oct 1, 2012 16.66%
Operational/Managerial ControlManaging Partner Jan 1, 2015 100%

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 13

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 13

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1740009600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1740009600000",
    "number": "1043016124",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "947 SOUTH 5TH STREET",
            "city": "MONTROSE",
            "state": "CO",
            "postal_code": "81401",
            "telephone_number": "970-249-2421",
            "fax_number": "855-638-4966"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "242 COTTONWOOD ST",
            "city": "DELTA",
            "state": "CO",
            "postal_code": "814164403",
            "telephone_number": "970-874-7552",
            "fax_number": "855-638-4966"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PEDIATRIC ASSOCIATES PROF LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PEDIATRIC ASSOCIATES PROF LLC",
        "enumeration_date": "2025-02-20",
        "last_updated": "2025-02-20",
        "certification_date": "2025-02-20",
        "status": "A",
        "authorized_official_last_name": "HICKERT",
        "authorized_official_first_name": "AMBER",
        "authorized_official_title_or_position": "PRACTICE ADMINISTRATOR",
        "authorized_official_telephone_number": "970-249-2421"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Delta, CO

Sources for this page

Verify at the official NPI Registry.