Basic Information
Provider Information | |||||||||
NPI: | 1962150243 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ROCKY MOUNTAIN CANCER CENTERS LLP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7951 E MAPLEWOOD AVE STE 350 | ||||||||
Address2: |   | ||||||||
City: | GREENWOOD VILLAGE | ||||||||
State: | CO | ||||||||
PostalCode: | 801114758 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3039307800 | ||||||||
FaxNumber: | 3039305503 | ||||||||
Practice Location | |||||||||
Address1: | 6031 E WOODMEN RD STE 200 | ||||||||
Address2: |   | ||||||||
City: | COLORADO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 809232625 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195772555 | ||||||||
FaxNumber: | 7195772553 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/15/2022 | ||||||||
LastUpdateDate: | 03/15/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WORTHAM | ||||||||
AuthorizedOfficialFirstName: | NANCY | ||||||||
AuthorizedOfficialMiddleName: | R. | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR CREDENTIALING COORDINATOR | ||||||||
AuthorizedOfficialTelephone: | 3039307803 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ROCKY MOUNTAIN CANCER CENTERS LLP | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/15/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
No ID Information.