1093780918 NPI number — C. KEITH FUJISAKI MD, PC

Table of content: (NPI 1093780918)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093780918 NPI number — C. KEITH FUJISAKI MD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
C. KEITH FUJISAKI 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:
SPORTS MEDICINE OF THE ROCKIES
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:
1093780918
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3455 LUTHERAN PKWY
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
WHEAT RIDGE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80033-6017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-403-7340
Provider Business Mailing Address Fax Number:
303-403-7347

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3455 LUTHERAN PKWY
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
WHEAT RIDGE
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80033-6017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-403-7340
Provider Business Practice Location Address Fax Number:
303-403-7347
Provider Enumeration Date:
02/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FUJISAKI
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
KEITH
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
303-403-7340

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  29370 , 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: 4213838 . This is a "AETNA" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: P00049979 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 104267500 . This is a "FEDERAL WORKMAN'T COMP" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 20872771 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: FUA29319 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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