Provider Demographics
NPI:1467526186
Name:WHEAT RIDGE GENERAL AND VASCULAR SURGICAL ASSOCIATES PC
Entity Type:Organization
Organization Name:WHEAT RIDGE GENERAL AND VASCULAR SURGICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEFEYTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-431-2900
Mailing Address - Street 1:7805 W 38TH AVE
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-6109
Mailing Address - Country:US
Mailing Address - Phone:303-431-2900
Mailing Address - Fax:303-431-2999
Practice Address - Street 1:7805 W 38TH AVE
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-6109
Practice Address - Country:US
Practice Address - Phone:303-431-2900
Practice Address - Fax:303-431-2999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO29993261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04020210Medicaid
COC315908Medicare ID - Type UnspecifiedMEDICARE PROVIDER #