Basic Information
| Provider Information | |||||||||
| NPI: | 1538267539 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PORTERCARE ADVENTIST HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CENTURA HEALTH - PORTER ADVENTIST HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT 105 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802910105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037781955 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2525 S. DOWNING ST. | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037781955 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BLAIR | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3037785893 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 05064001 | 05 | CO | MEDICAID |