1922005610 NPI number — WILLIAM G SELF JR MD PC

Table of content: (NPI 1922005610)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922005610 NPI number — WILLIAM G SELF JR MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLIAM G SELF JR MD PC
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:
Provider Other Organization Name Type Code:
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:
1922005610
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8403 BRYANT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTMINSTER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80031-3809
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-426-4810
Provider Business Mailing Address Fax Number:
303-426-8708

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8403 BRYANT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTMINSTER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80031-3809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-426-4810
Provider Business Practice Location Address Fax Number:
303-426-8708
Provider Enumeration Date:
07/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MONTGOMERY
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
303-426-4810

Provider Taxonomy Codes

  • Taxonomy code: 261QS0132X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 37801 . This is a "BLUE CROSS/BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 84078518A000 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 04510095 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 490000213 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8163314 . This is a "AETNA PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0971086 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".




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