Basic Information
Provider Information | |||||||||
NPI: | 1255949608 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ROCKY MOUNTAIN CANCER CENTERS, LLP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ROCKY MOUNTAIN CANCER CENTER, A PROFESSIONAL LLP | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7951 E MAPLEWOOD AVE STE 300 | ||||||||
Address2: |   | ||||||||
City: | GREENWOOD VILLAGE | ||||||||
State: | CO | ||||||||
PostalCode: | 801114726 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3039307895 | ||||||||
FaxNumber: | 3032674477 | ||||||||
Practice Location | |||||||||
Address1: | 1800 N WILLIAMS ST STE 100 | ||||||||
Address2: |   | ||||||||
City: | DENVER | ||||||||
State: | CO | ||||||||
PostalCode: | 802181237 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3032855020 | ||||||||
FaxNumber: | 3032855097 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/21/2020 | ||||||||
LastUpdateDate: | 05/07/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JESSE | ||||||||
AuthorizedOfficialFirstName: | FROYA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR CREDENTIALING COORDINATOR | ||||||||
AuthorizedOfficialTelephone: | 3039307895 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/07/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.