1528190295 NPI number — OPTUMCARE COLORADO MEDICAL GROUP LLC

Table of content: (NPI 1528190295)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528190295 NPI number — OPTUMCARE COLORADO MEDICAL GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTUMCARE COLORADO MEDICAL GROUP 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:
OPTUMCARE COLORADO SPRINGS LLC
Provider Other Organization Name Type Code:
4
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:
1528190295
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 S CASCADE AVE
Provider Second Line Business Mailing Address:
SUITE 140
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80903-1653
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-538-2900
Provider Business Mailing Address Fax Number:
719-538-2961

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1615 MEDICAL CENTER POINT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80907-1906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-636-3555
Provider Business Practice Location Address Fax Number:
719-667-4222
Provider Enumeration Date:
03/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
COHEN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
I
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
702-480-2550

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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