Basic Information
| Provider Information | |||||||||
| NPI: | 1639207095 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIVERSIFIED RADIOLOGY OF COLORADO, PC | ||||||||
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| OtherOrganizationName: | INTERVENTIONAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 938 BANNOCK ST | ||||||||
| Address2: | STE 300 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802044028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039148800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1601 E 19TH AVE | ||||||||
| Address2: | STE 3850 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802181216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032267225 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 09/28/2007 | ||||||||
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| AuthorizedOfficialLastName: | MCMILLAN | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3039148800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 04004826 | 05 | CO | MEDICAID |