Basic Information
| Provider Information | |||||||||
| NPI: | 1073593562 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BREYER | ||||||||
| FirstName: | KLEMENTYNA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BREYER | ||||||||
| OtherFirstName: | KLEMENTYNA | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 351750 | ||||||||
| Address2: | UNION HOSPITAL | ||||||||
| City: | WESTMINSTER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034848404 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8300 W 38TH AVE | ||||||||
| Address2: | UNION HOSPITAL | ||||||||
| City: | WHEAT RIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800336005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034848404 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 04/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 49448 | CO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 66371881 | 05 | CO | MEDICAID | 407386000 | 05 | MD | MEDICAID |