Basic Information
| Provider Information | |||||||||
| NPI: | 1154357788 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHERRY CREEK IMAGING, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 809 | ||||||||
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| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802060809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034681395 | ||||||||
| FaxNumber: | 3033557865 | ||||||||
| Practice Location | |||||||||
| Address1: | 12687 W CEDAR DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802282010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033554674 | ||||||||
| FaxNumber: | 3033557865 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 12/13/2011 | ||||||||
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| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3033554674 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | 58952225 | 05 | CO | MEDICAID | C554478 | 01 | CO | TRAILBLAZER MEDICAR | OTHER |