Basic Information
| Provider Information | |||||||||
| NPI: | 1326132291 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MADISON STREET SURGERY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 MADISON STREET | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802065419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033772020 | ||||||||
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| Practice Location | |||||||||
| Address1: | 55 MADISON ST | ||||||||
| Address2: | 200 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802065419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033880599 | ||||||||
| FaxNumber: | 3033889805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 02/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | NEAL | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4692140144 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1548219934 | 01 | CO | NPI | OTHER |