NPIMap

Organization Active NPI

Pediatric Associates Prof LLC

  • Rural Health Clinic/Center
  • Montrose, CO
National Provider Identifier
1780480855
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
947 S 5TH St
Montrose, CO 81401-5716
Phone
(970) 249-2421
Fax
(855) 638-4966
NPI assigned
Feb 20, 2025
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
Mrs. 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

947 S 5TH St
Montrose, CO 81401-5716

Mailing address

947 S 5TH St
Montrose, CO 81401-5716
Phone (970) 249-2421

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050113000921 CO Part A Provider - Rural Health Clinic 3375592637 1 other NPI on this enrollment
Practice locations: Montrose, CO

Rural health clinic certification: CCN 068901

Legal name
PEDIATRIC ASSOCIATES PROF LLC
Organization structure
LLCProprietary
Enrollment address
947 S 5TH St
Montrose, CO 81401-5716

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.

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 5% Or Greater Direct Ownership InterestPartner Jan 1, 2015 16.66%
Thomas Miller Individual 5% Or Greater Direct Ownership InterestPartner Jan 1, 2021 16.66%
Miroslawa Sikorska Individual 5% Or Greater Direct Ownership InterestPartner Jan 1, 2022 16.66%
Romeo G Icasiano Individual 5% Or Greater Direct Ownership InterestPartner Dec 1, 2004 16.66%
Libuse Engelbach Individual 5% Or Greater Direct Ownership InterestPartner Mar 22, 2012 16.66%
Gregory P Suchon Individual 5% Or Greater Direct Ownership InterestManaging Partner Dec 15, 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.

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": "1780480855",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "947 S 5TH ST",
            "city": "MONTROSE",
            "state": "CO",
            "postal_code": "814015716",
            "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": "947 S 5TH ST",
            "city": "MONTROSE",
            "state": "CO",
            "postal_code": "814015716",
            "telephone_number": "970-249-2421",
            "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",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Montrose, CO

Sources for this page

Verify at the official NPI Registry.