SOUTH DENVER PHYSICIANS PLLC - NPI NUMBER 1124463161

Summary

Provider Name: SOUTH DENVER PHYSICIANS PLLC

NPI Number: 1124463161

Clasification: Psychiatry & Neurology (2084N0400X)

Specialization: Neurology

Address:
13111 E BRIARWOOD AVE
#370
CENTENNIAL, CO
ZIP 80112

Phone Number: (720) 441-4410



Detailed Information

SOUTH DENVER PHYSICIANS PLLC is a neurologist in Centennial, CO. The provider is a Neurologist specializes in the diagnosis and treatment of diseases or impaired function of the brain, spinal cord, peripheral nerves, muscles, autonomic nervous system, and blood vessels that relate to these structures. The assigned NPI number for this provider is 1124463161 and is registered as an organization entity type and is a multi-specialty group.

The provider's business address is:

13111 E BRIARWOOD AVE
#370
CENTENNIAL, CO
ZIP 80112
Phone: (720) 441-4410
Fax: (888) 474-7158

The provider's authorized official is Dmitriy I Pales .
The authorized official title is Sole Member and has the following contact phone number (720) 441-4410.

The enumeration date for this NPI number is 5/3/2013 and was last updated on 3/13/2014.

Map - Location of Practice

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Taxonomy Codes

The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1 2084N0400X Psychiatry & Neurology Neurology 47080 CO No
2 207R00000X Internal Medicine 46797 CO Yes

Other (Legacy) Identifiers

The following legacy identifiers are available for this provider:

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
1 148761 MEDICAID CO

NPI Record

No. Field Name Field Value Field Definition 1
1 NPI 1124463161 Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No
2 Entity Type Code 2 Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
3 Employer Identification Number EIN The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
4 Provider Organization Name Legal Business Name SOUTH DENVER PHYSICIANS PLLC The name of the organization provider. If the provider is an organization, this is the legal business name.
5 Provider First Line Business Practice Location Address 13111 E BRIARWOOD AVE The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
6 Provider Second Line Business Practice Location Address #370 The second line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
7 Provider Business Practice Location Address City Name CENTENNIAL The city name in the location address of the provider being identified.
8 Provider Business Practice Location Address State Name CO The State code in the location of the provider being identified.
9 Provider Business Practice Location Address Postal Code 80112 The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
10 Provider Business Practice Location Address Country Code If outside U S US The country code in the location address of the provider being identified.
11 Provider Business Practice Location Address Telephone Number 7204414410 The telephone number associated with the location address of the provider being identified.
12 Provider Business Practice Location Address Fax Number 8884747158 The fax number associated with the location address of the provider being identified.
13 Provider Enumeration Date 5/3/2013 The date the provider was assigned a unique identifier (assigned an NPI).
14 Last Update Date 3/13/2014 The date that a record was last updated or changed.
15 Authorized Official Last Name PALES The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
16 Authorized Official First Name DMITRIY The first name of the authorized official.
17 Authorized Official Middle Name I The middle name of the authorized official.
18 Authorized Official Title or Position SOLE MEMBER The title or position of the authorized official.
19 Authorized Official Telephone Number 7204414410 The 10-position telephone number of the authorized official.
20 Healthcare Provider Taxonomy Code 1 2084N0400X Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
21 Provider License Number 1 47080 The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’.
22 Provider License Number State Code 1 CO The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number.
23 Healthcare Provider Primary Taxonomy Switch 1 N
24 Healthcare Provider Taxonomy Code 2 207R00000X
25 Provider License Number 2 46797 The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’.
26 Provider License Number State Code 2 CO The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number.
27 Healthcare Provider Primary Taxonomy Switch 2 Y
28 Other Provider Identifier 1 148761 Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
29 Other Provider Identifier Type Code 1 05 Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
30 Other Provider Identifier State 1 CO
31 Is Organization Subpart N
32 Authorized Official Credential Text DO
33 Healthcare Provider Taxonomy Group 1 193200000X MULTI-SPECIALTY GROUP
34 Healthcare Provider Taxonomy Group 2 193200000X MULTI-SPECIALTY GROUP

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This page was last updated on: 3/10/2015

(1) Field Definition Source-. Federal Register / Vol. 69, No. 15 / Friday, January 23, 2004 / Rules and Regulations - Part II Department of Health and Human Services Office of the Secretary 45 CFR Part 162 HIPAA Administrative Simplification: Standard Unique Health Identifier for Health Care Providers; Final Rule

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