Basic Information
| Provider Information | |||||||||
| NPI: | 1609916741 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HCA-HEALTHONE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | DENVER INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4545 E 9TH AVE | ||||||||
| Address2: | SUITE 630 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802203901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033202929 | ||||||||
| FaxNumber: | 3033202767 | ||||||||
| Practice Location | |||||||||
| Address1: | 4545 E 9TH AVE | ||||||||
| Address2: | SUITE 630 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802203901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033202929 | ||||||||
| FaxNumber: | 3033202767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 01/28/2008 | ||||||||
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| AuthorizedOfficialLastName: | CONNELLY | ||||||||
| AuthorizedOfficialFirstName: | JAC | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3033202035 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HCA-HEALTHONE, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | CI1305 | 01 | CO | RAILROAD MEDICARE | OTHER | 04021853 | 05 | CO | MEDICAID |