Basic Information
| Provider Information | |||||||||
| NPI: | 1215201454 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KAISER FOUNDATION HEALTH PLAN OF COLORADO | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KAISER PERMANENTE PUEBLO NORTH MEDICAL OFFICES LABORATORY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10350 E DAKOTA AVE | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802471314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033384545 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3670 PARKER BLVD | ||||||||
| Address2: | STE 200 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810082285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033384545 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2012 | ||||||||
| LastUpdateDate: | 05/24/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RAMSEIER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3033447256 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KAISER FOUNDATION HEALTH PLAN | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 09171088 | 05 | CO | MEDICAID |