Basic Information
| Provider Information | |||||||||
| NPI: | 1477711901 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RADAIDEH | ||||||||
| FirstName: | SOFYAN | ||||||||
| MiddleName: | MORSHED TALEB | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7951 E MAPLEWOOD AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD VILLAGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801114726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039307800 | ||||||||
| FaxNumber: | 3039307860 | ||||||||
| Practice Location | |||||||||
| Address1: | 3676 PARKER BLVD STE 350 | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810082213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192966000 | ||||||||
| FaxNumber: | 7195451146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2008 | ||||||||
| LastUpdateDate: | 03/18/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 49587 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 37557874 | 05 | CO | MEDICAID |