Basic Information
| Provider Information | |||||||||
| NPI: | 1518963214 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH DENVER INTEGRATED IMAGING LLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DENVER INTEGRATED IMAGING SOUTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 99 INVERNESS DR E STE 110 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801125122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037570332 | ||||||||
| FaxNumber: | 3037570558 | ||||||||
| Practice Location | |||||||||
| Address1: | 99 INVERNESS DR E STE 110 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801125122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037570332 | ||||||||
| FaxNumber: | 3037570558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2005 | ||||||||
| LastUpdateDate: | 07/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BALLARD | ||||||||
| AuthorizedOfficialFirstName: | DON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3037570332 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 18782078 | 05 | CO | MEDICAID |