1386647543 NPI number — COLORADO PROFESSIONAL MEDICAL, INC

Table of content: (NPI 1386647543)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386647543 NPI number — COLORADO PROFESSIONAL MEDICAL, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLORADO PROFESSIONAL MEDICAL, INC
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:
1386647543
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11750 W 2ND PL
Provider Second Line Business Mailing Address:
ST. ANTHONY MEDICAL PLAZA
Provider Business Mailing Address City Name:
LAKEWOOD
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80228-1575
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-233-2001
Provider Business Mailing Address Fax Number:
303-233-6390

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11750 W 2ND PL
Provider Second Line Business Practice Location Address:
ST. ANTHONY MEDICAL PLAZA
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80228-1575
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-233-2001
Provider Business Practice Location Address Fax Number:
303-233-6390
Provider Enumeration Date:
05/23/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PRICE
Authorized Official First Name:
SHERYL
Authorized Official Middle Name:
S
Authorized Official Title or Position:
DIRECTOR OF REIMBURSEMENT
Authorized Official Telephone Number:
503-493-8288

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  05-37672-0000 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 335E00000X , with the licence number: 05-37672-0000 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 57472335 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".