Basic Information
Provider Information | |||||||||
NPI: | 1750478459 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VVMC DIVERSIFIED SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SURGICAL ASSOCIATES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 40000 | ||||||||
Address2: | C/O ADMINISTRATION | ||||||||
City: | VAIL | ||||||||
State: | CO | ||||||||
PostalCode: | 81658 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9704797272 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 181 W MEADOW DR | ||||||||
Address2: |   | ||||||||
City: | VAIL | ||||||||
State: | CO | ||||||||
PostalCode: | 816575242 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9704797185 | ||||||||
FaxNumber: | 9705697453 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/06/2006 | ||||||||
LastUpdateDate: | 09/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HIGGINS | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | DAVID | ||||||||
AuthorizedOfficialTitleorPosition: | SVP CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 9704795131 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.