1700731445 NPI number — MADISON STREET PROVIDER NETWORK, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700731445 NPI number — MADISON STREET PROVIDER NETWORK, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MADISON STREET PROVIDER NETWORK, 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:
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:
1700731445
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 912914
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80291-2914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-377-2020
Provider Business Mailing Address Fax Number:
303-377-2022

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 INDIANA ST STE 220
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOLDEN
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80401-5095
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-377-2020
Provider Business Practice Location Address Fax Number:
303-377-2022
Provider Enumeration Date:
02/27/2026

Additional Information

Authorized Official

Authorized Official Last Name:
GROSS
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
303-586-9390

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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