Basic Information
| Provider Information | |||||||||
| NPI: | 1699895755 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROCKY MOUNTAIN PEDIATRIC GASTROENTEROLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10465 PARK MEADOWS DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | LONE TREE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801245321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037901515 | ||||||||
| FaxNumber: | 3037901989 | ||||||||
| Practice Location | |||||||||
| Address1: | 10465 PARK MEADOWS DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | LONE TREE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801245321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037901515 | ||||||||
| FaxNumber: | 3037901989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2007 | ||||||||
| LastUpdateDate: | 03/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | STATHOS | ||||||||
| AuthorizedOfficialFirstName: | THEODORE | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL, PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3037901515 | ||||||||
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| 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 | 2080P0206X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 04018362 | 05 | CO | MEDICAID |