1720015092 NPI number — SUMMIT MEDICAL GROUP OF COLORADO PC

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 1720015092 NPI number — SUMMIT MEDICAL GROUP OF COLORADO PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUMMIT MEDICAL GROUP OF COLORADO 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:
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:
1720015092
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
499 E HAMPDEN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ENGLEWOOD
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80113-2780
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-689-0088
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1776 E WARM SPRINGS RD
Provider Second Line Business Practice Location Address:
208
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89119-4676
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-932-8547
Provider Business Practice Location Address Fax Number:
702-932-8586
Provider Enumeration Date:
06/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
THATCHER
Authorized Official First Name:
MALISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING PERSON
Authorized Official Telephone Number:
702-932-8547

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)

  • Identifier: 27077527 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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