Provider Demographics
NPI:1376985168
Name:MADISON STREET COMPANY NURSE PRACTITIONER LLC
Entity Type:Organization
Organization Name:MADISON STREET COMPANY NURSE PRACTITIONER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ZEBARTH
Authorized Official - Suffix:
Authorized Official - Credentials:VP
Authorized Official - Phone:303-468-0432
Mailing Address - Street 1:55 MADISON ST
Mailing Address - Street 2:STE 355
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-5419
Mailing Address - Country:US
Mailing Address - Phone:303-377-2020
Mailing Address - Fax:303-377-2022
Practice Address - Street 1:55 MADISON ST
Practice Address - Street 2:STE 355
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-5419
Practice Address - Country:US
Practice Address - Phone:303-377-2020
Practice Address - Fax:303-377-2022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-23
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO44550782Medicaid
COC326124Medicare PIN