Basic Information
| Provider Information | |||||||||
| NPI: | 1205923596 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIVERSIFIED RADIOLOGY OF COLORADO, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1746 COLE BLVD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804013208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039148800 | ||||||||
| FaxNumber: | 3037163777 | ||||||||
| Practice Location | |||||||||
| Address1: | 1746 COLE BLVD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804013208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039148800 | ||||||||
| FaxNumber: | 3037163777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 04/30/2019 | ||||||||
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| AuthorizedOfficialLastName: | WALKER | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3039148800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 04004826 | 05 | CO | MEDICAID |