Provider Demographics
NPI:1154328508
Name:PARK AVENUE SURGERY CENTER LLC
Entity Type:Organization
Organization Name:PARK AVENUE SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:KIRK
Authorized Official - Last Name:POPHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-468-8844
Mailing Address - Street 1:1800 EMERSON ST
Mailing Address - Street 2:#200
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80218-1014
Mailing Address - Country:US
Mailing Address - Phone:303-468-8844
Mailing Address - Fax:303-468-8850
Practice Address - Street 1:1800 EMERSON ST
Practice Address - Street 2:#220
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1014
Practice Address - Country:US
Practice Address - Phone:303-468-8844
Practice Address - Fax:303-468-8850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0471261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0471OtherSTATE LICENSE