1063167211 NPI number — BIG TREE MEDICAL GROUP LLC

Table of content: (NPI 1063167211)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063167211 NPI number — BIG TREE MEDICAL GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BIG TREE 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:
Provider Other Organization Name Type Code:
6
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:
1063167211
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1701 S FEDERAL BLVD
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:
80219-4898
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
720-323-0621
Provider Business Mailing Address Fax Number:
303-934-4036

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1701 S FEDERAL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80219-4898
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-323-0621
Provider Business Practice Location Address Fax Number:
303-934-4036
Provider Enumeration Date:
02/16/2022

Additional Information

Authorized Official

Authorized Official Last Name:
VANBANG
Authorized Official First Name:
ANTONY
Authorized Official Middle Name:
NGUYEN
Authorized Official Title or Position:
PRIMARY PROVIDER
Authorized Official Telephone Number:
720-323-0621

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: DR.0054747 . This is a "COLORADO DEPARTMENT OF REGULATORY AGENCIES DIVISION OF PROFESSIONS AND OCCUPATIO" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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