1023234861 NPI number — PEDIATRIC ASSOCIATES OF SOUTHERN COLORADO, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023234861 NPI number — PEDIATRIC ASSOCIATES OF SOUTHERN COLORADO, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC ASSOCIATES OF SOUTHERN COLORADO, 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:
1023234861
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:
2020 WADSWORTH BLVD
Provider Second Line Business Mailing Address:
SUITE 13A
Provider Business Mailing Address City Name:
LAKEWOOD
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80214-5728
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-238-0471
Provider Business Mailing Address Fax Number:
303-238-6711

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1312 N GRAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81003-2718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-544-2090
Provider Business Practice Location Address Fax Number:
719-544-2094
Provider Enumeration Date:
04/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VEDANTHAN
Authorized Official First Name:
PUDUPAKKAM
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
303-238-0471

Provider Taxonomy Codes

  • Taxonomy code: 207K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 39188361 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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