Provider Demographics
NPI:1245781723
Name:OPTUMCARE COLORADO MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:OPTUMCARE COLORADO MEDICAL GROUP LLC
Other - Org Name:DAVITA MEDICAL GROUP COLORADO SPRINGS LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ASSOCIATE DIRECTOR CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-579-3253
Mailing Address - Street 1:6025 DELMONICO DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-2251
Mailing Address - Country:US
Mailing Address - Phone:719-538-2900
Mailing Address - Fax:719-538-2987
Practice Address - Street 1:6025 DELMONICO DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-2251
Practice Address - Country:US
Practice Address - Phone:719-535-0648
Practice Address - Fax:719-262-5574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO208D00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO06085288Medicaid
CO387379OtherMEDICARE ID