1578601969 NPI number — CREEKSIDE PHYSICAL MEDICINE PLLC

Table of content: (NPI 1578601969)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578601969 NPI number — CREEKSIDE PHYSICAL MEDICINE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CREEKSIDE PHYSICAL MEDICINE PLLC
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:
1578601969
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5387 MANHATTAN CIR
Provider Second Line Business Mailing Address:
STE 201
Provider Business Mailing Address City Name:
BOULDER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80303-4284
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-494-2705
Provider Business Mailing Address Fax Number:
303-494-2706

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5387 MANHATTAN CIR
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
BOULDER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80303-4284
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-494-2705
Provider Business Practice Location Address Fax Number:
303-494-2706
Provider Enumeration Date:
02/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TANNER
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRINCIPAL CLINICIAN
Authorized Official Telephone Number:
303-494-2705

Provider Taxonomy Codes

  • Taxonomy code: 204D00000X , with the licence number:  38635 , 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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