Basic Information
| Provider Information | |||||||||
| NPI: | 1386683340 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUBSPECIALTY IMAGING PARTNERS PROF, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3079 | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD VILLAGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801553079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 3037616322 | ||||||||
| Practice Location | |||||||||
| Address1: | 10700 E GEDDES AVE | ||||||||
| Address2: | #200 | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801123800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 3037616322 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 10/31/2007 | ||||||||
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| AuthorizedOfficialLastName: | BERRIAN | ||||||||
| AuthorizedOfficialFirstName: | MARNIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3037619190 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 66638739 | 05 | CO | MEDICAID |