Basic Information
| Provider Information | |||||||||
| NPI: | 1801493911 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NATIONAL JEWISH HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NATIONAL JEWISH HEALTH PROVIDER GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802062761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033884461 | ||||||||
| FaxNumber: | 3033981211 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802062761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033884461 | ||||||||
| FaxNumber: | 3033981211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2020 | ||||||||
| LastUpdateDate: | 01/18/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEDINA | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, MEDICAL STAFF SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 3033884461 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NATIONAL JEWISH HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | CJ6004 | 01 | CO | MEDICARE PTAN | OTHER | 04001905 | 05 | CO | MEDICAID |