Basic Information
| Provider Information | |||||||||
| NPI: | 1639669617 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UCH-MHS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | UCHEALTH EMERGENCY ROOM - MEADOWGRASS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7901 E LOWRY BLVD | ||||||||
| Address2: | F402, 3RD FLOOR | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7205531700 | ||||||||
| FaxNumber: | 7205531754 | ||||||||
| Practice Location | |||||||||
| Address1: | 13510 MEADOWGRASS DR | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809213056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194872060 | ||||||||
| FaxNumber: | 7194872064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2018 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MATSON | ||||||||
| AuthorizedOfficialFirstName: | DOREEN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7193652062 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UCH-MHS | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | N | Hospitals | General Acute Care Hospital | 261QE0002X | Y | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care |
No ID Information.