Basic Information
| Provider Information | |||||||||
| NPI: | 1104817055 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROCKY MOUNTAIN PEDIATRIC SURGERY, P.C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 E 19TH AVE | ||||||||
| Address2: | SUITE 5500 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802181216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038396001 | ||||||||
| FaxNumber: | 3038396033 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 E 19TH AVE | ||||||||
| Address2: | SUITE 5500 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802181216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038396001 | ||||||||
| FaxNumber: | 3038396033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROTHENBERG | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3038396001 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 04008462 | 05 | CO | MEDICAID |