Basic Information
| Provider Information | |||||||||
| NPI: | 1407206725 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERNAL MEDICINE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 W DRY CREEK CIR | ||||||||
| Address2: | |||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801204427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039521100 | ||||||||
| FaxNumber: | 7202873183 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 W DRY CREEK CIR | ||||||||
| Address2: | |||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801204427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039521100 | ||||||||
| FaxNumber: | 7202873183 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2016 | ||||||||
| LastUpdateDate: | 11/06/2022 | ||||||||
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| AuthorizedOfficialLastName: | PORTNOY | ||||||||
| AuthorizedOfficialFirstName: | JOSHUA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3033458291 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | CO | MEDICAID |