Basic Information
| Provider Information | |||||||||
| NPI: | 1518162429 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH DENVER SPINE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15530 E BRONCOS PKWY | ||||||||
| Address2: | #100 | ||||||||
| City: | CENTENNIAL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801127111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7208512000 | ||||||||
| FaxNumber: | 7208512009 | ||||||||
| Practice Location | |||||||||
| Address1: | 15530 E BRONCOS PKWY | ||||||||
| Address2: | #100 | ||||||||
| City: | CENTENNIAL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7208512000 | ||||||||
| FaxNumber: | 7208512009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2007 | ||||||||
| LastUpdateDate: | 07/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | IBRAHIM | ||||||||
| AuthorizedOfficialFirstName: | ZAKI | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7208512000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 07/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207X00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1518162429 | 01 | CO | GROUP NPI NUMBER | OTHER | 1689612889 | 01 | CO | ZAKI G IBRAHIM, MD | OTHER | 47479221 | 05 | CO | MEDICAID |