Basic Information
| Provider Information | |||||||||
| NPI: | 1831738061 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NATIONAL JEWISH HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NATIONAL JEWISH NORTHERN ONCOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802062762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033884461 | ||||||||
| FaxNumber: | 3032702366 | ||||||||
| Practice Location | |||||||||
| Address1: | NATIONAL JEWISH NORTH | ||||||||
| Address2: | 9451 HURON STREET | ||||||||
| City: | THORNTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802605426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036504042 | ||||||||
| FaxNumber: | 3036504046 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2020 | ||||||||
| LastUpdateDate: | 01/19/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEDINA | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, MEDICAL STAFF SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 3033884461 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Oncology |
ID Information
| ID | Type | State | Issuer | Description | 0500112 | 05 | CO | MEDICAID | 1326015777 | 01 | CO | MEDICAID OFFSHOOT | OTHER |