Basic Information
| Provider Information | |||||||||
| NPI: | 1245430826 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KEMMIS | ||||||||
| FirstName: | TYLER | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 ELDORADO BLVD | ||||||||
| Address2: | SUITE 6250 | ||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800213408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032720750 | ||||||||
| FaxNumber: | 3033182488 | ||||||||
| Practice Location | |||||||||
| Address1: | 8300 W 38TH AVE | ||||||||
| Address2: | |||||||||
| City: | WHEAT RIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800336005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034678903 | ||||||||
| FaxNumber: | 3034678921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2007 | ||||||||
| LastUpdateDate: | 12/31/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 48720 | CO | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 83178279 | 05 | CO | MEDICAID |