Basic Information
| Provider Information | |||||||||
| NPI: | 1164828026 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CATHOLIC HEALTH INITIATIVES COLORADO | ||||||||
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| OtherOrganizationName: | CENTURA HEALTH PHYSICIAN GROUP SAH INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911057 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802911057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036431099 | ||||||||
| FaxNumber: | 3036431176 | ||||||||
| Practice Location | |||||||||
| Address1: | 11750 W 2ND PL | ||||||||
| Address2: | SUITE 365 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802281575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7203218280 | ||||||||
| FaxNumber: | 7203218281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2014 | ||||||||
| LastUpdateDate: | 04/20/2016 | ||||||||
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| AuthorizedOfficialLastName: | SKINNER | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OMA ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3036737175 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 53037375 | 05 | CO | MEDICAID |