1134149594 NPI number — COLORADO HEART CLINIC PROFESSIONAL LLC

Table of content: (NPI 1134149594)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134149594 NPI number — COLORADO HEART CLINIC PROFESSIONAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLORADO HEART CLINIC PROFESSIONAL LLC
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:
DR TRACY PAESCHKE & DR VITO CALANDRO
Provider Other Organization Name Type Code:
5
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:
1134149594
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
850 E HARVARD AVE
Provider Second Line Business Mailing Address:
STE 365
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80210-5076
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-778-1171
Provider Business Mailing Address Fax Number:
303-778-1674

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
850 E HARVARD AVE
Provider Second Line Business Practice Location Address:
STE 365
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80210-5076
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-778-1171
Provider Business Practice Location Address Fax Number:
303-778-1674
Provider Enumeration Date:
07/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FOX
Authorized Official First Name:
BRENDA
Authorized Official Middle Name:
S
Authorized Official Title or Position:
INSURANCE BILLER
Authorized Official Telephone Number:
303-778-1171

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  41162 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: 41133 , 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: 41162 . This is a "DR TRACY PAESCHKE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 41133 . This is a "DR VITO CALANDRO" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 95178732 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11827238 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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