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
1 NPI 1124463161
2 Entity Type Code 2
3 Employer Identification Number EIN
4 Provider Organization Name Legal Business Name SOUTH DENVER PHYSICIANS PLLC
5 Provider First Line Business Practice Location Address 13111 E BRIARWOOD AVE
6 Provider Second Line Business Practice Location Address #370
7 Provider Business Practice Location Address City Name CENTENNIAL
8 Provider Business Practice Location Address State Name CO
9 Provider Business Practice Location Address Postal Code 80112
10 Provider Business Practice Location Address Country Code If outside U S US
11 Provider Business Practice Location Address Telephone Number 7204414410
12 Provider Business Practice Location Address Fax Number 8884747158
13 Provider Enumeration Date 5/3/2013
14 Last Update Date 3/13/2014
15 Authorized Official Last Name PALES
16 Authorized Official First Name DMITRIY
17 Authorized Official Middle Name I
18 Authorized Official Title or Position SOLE MEMBER
19 Authorized Official Telephone Number 7204414410
20 Healthcare Provider Taxonomy Code 1 2084N0400X
21 Provider License Number 1 47080
22 Provider License Number State Code 1 CO
23 Healthcare Provider Primary Taxonomy Switch 1 N
24 Healthcare Provider Taxonomy Code 2 207R00000X
25 Provider License Number 2 46797
26 Provider License Number State Code 2 CO
27 Healthcare Provider Primary Taxonomy Switch 2 Y
28 Other Provider Identifier 1 148761
29 Other Provider Identifier Type Code 1 05
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: 10/12/2014
All materials and services on this site are provided on an "as is" and "as available" basis without warranty of any kind. The NPI record is maintained by the National Plan & Provider Enumeration System (NPPES) and anyone may request this information and other NPPES health care provider data from HHS under The Freedom of Information Act (FOIA), Title 5 of the United States Code, section 552. To update the NPI records please contact the NPPES.