Basic Information
| Provider Information | |||||||||
| NPI: | 1245683879 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLORADO PERMANENTE MEDICAL GROUP, P.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KAISER PERMANENTE WATERPARK I | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10350 E DAKOTA AVE | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802471314 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2500 S HAVANA ST | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800141618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033384545 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2016 | ||||||||
| LastUpdateDate: | 05/25/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SPLINTER | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CPMG CFO | ||||||||
| AuthorizedOfficialTelephone: | 3033447345 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COLORADO PERMANENTE MEDICAL GROUP, P.C. | ||||||||
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| NPICertificationDate: | 05/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | CO | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 04710083 | 05 | CO | MEDICAID |