Basic Information
| Provider Information | |||||||||
| NPI: | 1144880675 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UCH-MHS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | MEMORIAL HEALTH SYSTEM | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 7901 E LOWRY BLVD | ||||||||
| Address2: | F402, 3RD FLOOR | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7205531700 | ||||||||
| FaxNumber: | 7205531754 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 OLYMPIC PLZ | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809095780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193651236 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2019 | ||||||||
| LastUpdateDate: | 01/09/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MATSON | ||||||||
| AuthorizedOfficialFirstName: | DOREEN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7193652062 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UCH-MHS | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 282N00000X | Y | Hospitals | General Acute Care Hospital |
No ID Information.