Basic Information
Provider Information | |||||||||
NPI: | 1942449426 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KAISER FOUNDATION HEALTH PLAN OF CO | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KAISER PERMANENTE PARKER MEDICAL OFFICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10350 E DAKOTA AVE | ||||||||
Address2: |   | ||||||||
City: | DENVER | ||||||||
State: | CO | ||||||||
PostalCode: | 802471314 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 10168 PARKGLENN WAY | ||||||||
Address2: |   | ||||||||
City: | PARKER | ||||||||
State: | CO | ||||||||
PostalCode: | 801383868 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3033384545 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/06/2009 | ||||||||
LastUpdateDate: | 04/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RAMSEIER | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | REGIONAL PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3033447256 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | KAISER FOUNDATION HEALTH PLAN OF CO | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/13/2021 |
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 | 04020087 | 05 | CO |   | MEDICAID | 04710083 | 05 | CO |   | MEDICAID | 30478251 | 05 | CO |   | MEDICAID |