Basic Information
| Provider Information | |||||||||
| NPI: | 1992114334 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CATHOLIC HEALTH INITIATIVES COLORADO | ||||||||
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| OtherOrganizationName: | CENTURA HEALTH PHYSICIAN GROUP ST THOMAS MORE PEDIATRIC HEALTH SVCS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911057 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802911057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036431099 | ||||||||
| FaxNumber: | 3036431176 | ||||||||
| Practice Location | |||||||||
| Address1: | 1335 PHAY AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CANON CITY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812122334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192852091 | ||||||||
| FaxNumber: | 7192852092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2014 | ||||||||
| LastUpdateDate: | 04/20/2016 | ||||||||
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| AuthorizedOfficialLastName: | SKINNER | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR OMA | ||||||||
| AuthorizedOfficialTelephone: | 3036737175 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 55906257 | 05 | CO | MEDICAID |