Basic Information
| Provider Information | |||||||||
| NPI: | 1043858889 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NATIONAL JEWISH SOUTH DENVER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NJH SOUTH DENVER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802062762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033884461 | ||||||||
| FaxNumber: | 3032702366 | ||||||||
| Practice Location | |||||||||
| Address1: | 499 E HAMPDEN AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801132793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037888500 | ||||||||
| FaxNumber: | 3037888505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2019 | ||||||||
| LastUpdateDate: | 01/19/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEDINA | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL STAFF SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 3033884461 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DIRECTOR | ||||||||
| NPICertificationDate: | 01/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 1043858889 | 05 | CO | MEDICAID | 1326015777 | 05 | CO | MEDICAID |