1073558474 NPI number — COLORADO DIAGNOSTIC MEDICINE, LLC

Table of content: (NPI 1073558474)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073558474 NPI number — COLORADO DIAGNOSTIC MEDICINE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLORADO DIAGNOSTIC MEDICINE, 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:
1073558474
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:
4374 RELIABLE PARKWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60686-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-839-9901
Provider Business Mailing Address Fax Number:
314-839-9902

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5920 S ESTES ST
Provider Second Line Business Practice Location Address:
STE. 150
Provider Business Practice Location Address City Name:
LITTLETON
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80123-8618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-948-5765
Provider Business Practice Location Address Fax Number:
303-948-5761
Provider Enumeration Date:
06/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HAIDER
Authorized Official First Name:
SYED
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
314-839-9901

Provider Taxonomy Codes

  • Taxonomy code: 261QM1200X , with the licence number:  NA , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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