Basic Information
Provider Information | |||||||||
NPI: | 1376970012 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PORTERCARE ADVENTIST HEALTH SYSTEM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CENTURA HEALTH PHYSICIAN GROUP CASTLE ROCK ENT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 911244 | ||||||||
Address2: |   | ||||||||
City: | DENVER | ||||||||
State: | CO | ||||||||
PostalCode: | 802911244 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3036431099 | ||||||||
FaxNumber: | 3036431176 | ||||||||
Practice Location | |||||||||
Address1: | 2352 MEADOWS BLVD | ||||||||
Address2: | SUITE 300 | ||||||||
City: | CASTLE ROCK | ||||||||
State: | CO | ||||||||
PostalCode: | 801098406 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7204553800 | ||||||||
FaxNumber: | 7204553801 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/26/2013 | ||||||||
LastUpdateDate: | 04/28/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SKINNER | ||||||||
AuthorizedOfficialFirstName: | ANGELA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OMA ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 3036737175 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |   |
ID Information
ID | Type | State | Issuer | Description | 55239757 | 05 | CO |   | MEDICAID |