Provider Demographics
NPI:1407487788
Name:OPTUMCARE COLORADO MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:OPTUMCARE COLORADO MEDICAL GROUP LLC
Other - Org Name:BROADMOOR VALLEY PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:I
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-480-2550
Mailing Address - Street 1:2 S CASCADE AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-1604
Mailing Address - Country:US
Mailing Address - Phone:719-538-2900
Mailing Address - Fax:719-538-2996
Practice Address - Street 1:1230 TENDERFOOT HILL RD STE 255
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-7393
Practice Address - Country:US
Practice Address - Phone:719-576-5437
Practice Address - Fax:719-576-5441
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OPTUMCARE COLORADO MEDICAL GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-01-27
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty