Basic Information
| Provider Information | |||||||||
| NPI: | 1659313062 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SENIOR CARE OF COLORADO, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2400 S PEORIA ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800145476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033064321 | ||||||||
| FaxNumber: | 3033693022 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 S PEORIA ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800145476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033064321 | ||||||||
| FaxNumber: | 3033693022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2006 | ||||||||
| LastUpdateDate: | 08/19/2010 | ||||||||
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| AuthorizedOfficialLastName: | WASSERMAN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3033064315 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207RG0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 17739217 | 05 | CO | MEDICAID |