1346360617 NPI number — SPRUCE STREET INTERNAL MEDICINE

Table of content: (NPI 1346360617)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346360617 NPI number — SPRUCE STREET INTERNAL MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPRUCE STREET INTERNAL MEDICINE
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:
1346360617
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2575 SPRUCE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOULDER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-449-3594
Provider Business Mailing Address Fax Number:
303-449-3112

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2575 SPRUCE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOULDER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-449-3594
Provider Business Practice Location Address Fax Number:
303-449-3112
Provider Enumeration Date:
03/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BROWNE
Authorized Official First Name:
HILLARY
Authorized Official Middle Name:
LOIS
Authorized Official Title or Position:
MD/OWNER
Authorized Official Telephone Number:
303-449-3594

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  30069 , 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)





Copyright © 2007-2024 www.npivalidator.com