Basic Information
| Provider Information | |||||||||
| NPI: | 1689748758 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PARK AVENUE SURGERY CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 EMERSON ST | ||||||||
| Address2: | STE 200 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034688844 | ||||||||
| FaxNumber: | 3034688850 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 EMERSON ST | ||||||||
| Address2: | STE 200 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034688844 | ||||||||
| FaxNumber: | 3034688850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 06/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | POPHAM | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3034688844 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 0769 | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 88530221 | 05 | CO | MEDICAID |