1174567861 NPI number — RUTH ANITA VANDERKOOI MD

Table of content: RUTH ANITA VANDERKOOI MD (NPI 1174567861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174567861 NPI number — RUTH ANITA VANDERKOOI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDERKOOI
Provider First Name:
RUTH
Provider Middle Name:
ANITA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOSCH
Provider Other First Name:
RUTH
Provider Other Middle Name:
ANITA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174567861
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 ELDORADO BLVD # 6250
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOMFIELD
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80021-3408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-272-0751
Provider Business Mailing Address Fax Number:
303-318-2488

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8350 WCR 13 UNIT 160
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FIRESTONE
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80504-6803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-689-5160
Provider Business Practice Location Address Fax Number:
303-689-5175
Provider Enumeration Date:
06/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  31315 , 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)

  • Identifier: 01313154 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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