Basic Information
| Provider Information | |||||||||
| NPI: | 1215268974 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PORTERCARE ADVENTIST HEALTH SYSTEMS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AVISTA FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911244 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802911244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036431099 | ||||||||
| FaxNumber: | 3036431176 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 MITCHELL WAY | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | ERIE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805165441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032692780 | ||||||||
| FaxNumber: | 3032692790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2010 | ||||||||
| 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 | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 97080373 | 05 | CO | MEDICAID |