Basic Information
| Provider Information | |||||||||
| NPI: | 1215918586 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTHONE CLINIC SERVICES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEALTHONE LODO INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1515 WAZEE ST | ||||||||
| Address2: | SUITE D | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802021478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035349550 | ||||||||
| FaxNumber: | 3039327805 | ||||||||
| Practice Location | |||||||||
| Address1: | 1515 WAZEE ST | ||||||||
| Address2: | SUITE D | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802021478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035349550 | ||||||||
| FaxNumber: | 3039327805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BIRMINGHAM | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6153737625 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 | GR69051526 | 05 | CO | MEDICAID |