1417163536 NPI number — MATTHEW CHARLES GRZEGOZEWSKI

Table of content: MATTHEW CHARLES GRZEGOZEWSKI (NPI 1417163536)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417163536 NPI number — MATTHEW CHARLES GRZEGOZEWSKI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRZEGOZEWSKI
Provider First Name:
MATTHEW
Provider Middle Name:
CHARLES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRZEGOZEWSKI
Provider Other First Name:
MATTHEW
Provider Other Middle Name:
C.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1417163536
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 173862
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80217-3862
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-306-7783
Provider Business Mailing Address Fax Number:
303-306-7753

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10101 RIDGEGATE PARKWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONE TREE
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80124-9810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-225-1900
Provider Business Practice Location Address Fax Number:
303-306-7753
Provider Enumeration Date:
05/15/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  D66242 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: DR.0052852 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P01250125 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 99936383 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".