Basic Information
| Provider Information | |||||||||
| NPI: | 1366180507 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REGENTS OF THE UNIVERSITY OF COLORADO | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5001 S. PARKER ROAD | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033156200 | ||||||||
| FaxNumber: | 3036802255 | ||||||||
| Practice Location | |||||||||
| Address1: | 5001 S. PARKER ROAD | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033156200 | ||||||||
| FaxNumber: | 3036802255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2022 | ||||||||
| LastUpdateDate: | 07/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PHILLIPS | ||||||||
| AuthorizedOfficialFirstName: | TRACEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING LEAD | ||||||||
| AuthorizedOfficialTelephone: | 3033156176 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | REGENTS OF THE UNIVERSITY OF COLORADO | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.