Basic Information
| Provider Information | |||||||||
| NPI: | 1407252828 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OPTUMCARE COLORADO SPRINGS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DAVITA MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 S CASCADE AVE | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809031653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195382900 | ||||||||
| FaxNumber: | 7195382987 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 S CASCADE AVE | ||||||||
| Address2: | STE 140 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195382900 | ||||||||
| FaxNumber: | 7195382987 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2014 | ||||||||
| LastUpdateDate: | 02/10/2021 | ||||||||
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| AuthorizedOfficialLastName: | DOLVE | ||||||||
| AuthorizedOfficialFirstName: | DOROTHY | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7195382980 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | CO | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 06085288 | 05 | CO | MEDICAID |