Basic Information
| Provider Information | |||||||||
| NPI: | 1710969092 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PLATTE RIVER ANESTHESIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 668 | ||||||||
| Address2: | |||||||||
| City: | ARVADA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800010668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034229438 | ||||||||
| FaxNumber: | 3034229474 | ||||||||
| Practice Location | |||||||||
| Address1: | 1850 E EGBERT ST | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806012404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036591531 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SISK | ||||||||
| AuthorizedOfficialFirstName: | JERALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3036591531 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 35571250 | 05 | CO | MEDICAID |