Provider Demographics
NPI:1235685652
Name:COLORADO PERMANENTE MEDICAL GROUP, P.C.
Entity Type:Organization
Organization Name:COLORADO PERMANENTE MEDICAL GROUP, P.C.
Other - Org Name:KAISER PERMANENTE PUEBLO NORTH MEDICAL OFFICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CPMG CFO
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:SPLINTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-344-7345
Mailing Address - Street 1:10350 E DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-1314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3670 PARKER BLVD
Practice Address - Street 2:STE 200
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2285
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLORADO PERMANENTE MEDICAL GROUP, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-26
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04710083Medicaid
COCK10000Medicare PIN