1629030689 NPI number — PEDIATRICS 5280 PC

Table of content: (NPI 1629030689)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629030689 NPI number — PEDIATRICS 5280 PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRICS 5280 PC
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:
PEDIATRICS DTC PC
Provider Other Organization Name Type Code:
4
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:
1629030689
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9094 E MINERAL AVE
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
CENTENNIAL
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80112-7200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-779-5437
Provider Business Mailing Address Fax Number:
303-689-9628

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9094 E MINERAL AVE
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
CENTENNIAL
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80112-7200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-779-5437
Provider Business Practice Location Address Fax Number:
303-689-9628
Provider Enumeration Date:
04/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STAPP
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
HOLBROOK
Authorized Official Title or Position:
PRESIDENT PHYSICIAN
Authorized Official Telephone Number:
303-779-5437

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4013280 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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