Basic Information
| Provider Information | |||||||||
| NPI: | 1023001526 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LITTLETON INTERNAL MEDICINE ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7780 S BROADWAY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801222648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037989996 | ||||||||
| FaxNumber: | 3037301145 | ||||||||
| Practice Location | |||||||||
| Address1: | 7780 S BROADWAY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801222648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037989996 | ||||||||
| FaxNumber: | 3037301145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CONWAY | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3037989996 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 04016861 | 05 | CO | MEDICAID |