Basic Information
| Provider Information | |||||||||
| NPI: | 1386651297 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PORTERCARE ADVENTIST HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CENTURA PARKER ADVENTIST HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 801106 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641801106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009530104 | ||||||||
| FaxNumber: | 3037656670 | ||||||||
| Practice Location | |||||||||
| Address1: | 9395 CROWN CREST BLVD | ||||||||
| Address2: | |||||||||
| City: | PARKER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801388573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032694000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 03/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEARY | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | GROUP VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3036431022 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PORTERCARE ADVENTIST HEALTH SYSTEM | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 1005 | CO | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 56572271 | 05 | CO | MEDICAID |