1376645143 NPI number — DERMATOLOGY & LASER CENTER AT HARVARD PARK, PLLC

Table of content: (NPI 1376645143)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376645143 NPI number — DERMATOLOGY & LASER CENTER AT HARVARD PARK, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMATOLOGY & LASER CENTER AT HARVARD PARK, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DERMATOLOGY & LASER CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376645143
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
950 E HARVARD AVE
Provider Second Line Business Mailing Address:
STE 440
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80210-7009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-744-2704
Provider Business Mailing Address Fax Number:
303-744-3244

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
950 E HARVARD AVE
Provider Second Line Business Practice Location Address:
STE 440
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80210-7009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-744-2704
Provider Business Practice Location Address Fax Number:
303-744-3244
Provider Enumeration Date:
09/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EUBANKS
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
W
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
303-744-2704

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CH4005 . This is a "RR MEDICARE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 87557011 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: DE635330 . This is a "BCBS" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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