Basic Information
| Provider Information | |||||||||
| NPI: | 1891071627 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JAYDEEP MEDICAL PROFESSIONAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1115 | ||||||||
| Address2: | |||||||||
| City: | FORT MORGAN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 807011115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024533799 | ||||||||
| FaxNumber: | 7024535741 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 EDISON ST | ||||||||
| Address2: | |||||||||
| City: | BRUSH | ||||||||
| State: | CO | ||||||||
| PostalCode: | 807231640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708426200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2011 | ||||||||
| LastUpdateDate: | 10/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | LABRECQUE | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
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| AuthorizedOfficialTitleorPosition: | ACCTS. MGR | ||||||||
| AuthorizedOfficialTelephone: | 7024533799 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 47973 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 47973 | 01 | CO | CO LIC | OTHER |