Provider Demographics
NPI:1487026951
Name:SURGICAL SPECIALISTS OF COLORADO PLLC
Entity Type:Organization
Organization Name:SURGICAL SPECIALISTS OF COLORADO PLLC
Other - Org Name:CARAID CORPORATION
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:720-820-9455
Mailing Address - Street 1:14100 E ARAPAHOE RD STE 260
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80112-4048
Mailing Address - Country:US
Mailing Address - Phone:036-993-0483
Mailing Address - Fax:303-699-3047
Practice Address - Street 1:14100 E ARAPAHOE RD STE 260
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-4048
Practice Address - Country:US
Practice Address - Phone:303-699-3048
Practice Address - Fax:303-699-3047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
163WW0000X, 208600000X
CODR47517208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No163WW0000XNursing Service ProvidersRegistered NurseWound CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000171312Medicaid