1194266809 NPI number — BRIAR ROSE MEDICAL GROUP,LLC

Table of content: (NPI 1194266809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194266809 NPI number — BRIAR ROSE MEDICAL GROUP,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIAR ROSE 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:
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:
1194266809
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3350 PEORIA ST
Provider Second Line Business Mailing Address:
STE 120
Provider Business Mailing Address City Name:
AURORA
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80010-1483
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-355-7673
Provider Business Mailing Address Fax Number:
720-729-8100

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3350 PEORIA ST
Provider Second Line Business Practice Location Address:
STE 120
Provider Business Practice Location Address City Name:
AURORA
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80010-1483
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
844-355-7673
Provider Business Practice Location Address Fax Number:
720-729-8100
Provider Enumeration Date:
03/14/2017

Additional Information

Authorized Official

Authorized Official Last Name:
PONDER
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
CARSON
Authorized Official Title or Position:
CO-OWNER
Authorized Official Telephone Number:
844-355-7673

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  0054605 , 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: 33439257 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 24523348 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com