Provider Demographics
NPI:1417175514
Name:SOUTH FEDERAL FAMILY PRACTICE
Entity Type:Organization
Organization Name:SOUTH FEDERAL FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DURBIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-934-2202
Mailing Address - Street 1:1930 S FEDERAL BLVD
Mailing Address - Street 2:#A
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80219-5580
Mailing Address - Country:US
Mailing Address - Phone:303-934-2202
Mailing Address - Fax:303-934-1473
Practice Address - Street 1:1930 S FEDERAL BLVD
Practice Address - Street 2:#A
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80219-5580
Practice Address - Country:US
Practice Address - Phone:303-934-2202
Practice Address - Fax:303-934-1473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO034303260Medicaid
COCD2208Medicare PIN