Basic Information
| Provider Information | |||||||||
| NPI: | 1215910146 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LONGS PEAK EMERGENCY PHYSICIANS, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 1175 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801502568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033067783 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Practice Location | |||||||||
| Address1: | 1950 WEST MOUNTAIN VIEW AVE. | ||||||||
| Address2: | |||||||||
| City: | LONGMONT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805013129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036515000 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 12/18/2015 | ||||||||
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| AuthorizedOfficialLastName: | OGDEN | ||||||||
| AuthorizedOfficialFirstName: | HERBERT | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3036515000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 48184268 | 05 | CO | MEDICAID |