Provider Demographics
NPI:1619390234
Name:PORTERCARE ADVENTIST HEALTH SYSTEM
Entity Type:Organization
Organization Name:PORTERCARE ADVENTIST HEALTH SYSTEM
Other - Org Name:CENTURA HEALTH PHYSICIAN GROUP GI PAHS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR OMA
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:SKINNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-673-7175
Mailing Address - Street 1:PO BOX 911244
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-1244
Mailing Address - Country:US
Mailing Address - Phone:303-643-1099
Mailing Address - Fax:303-643-1176
Practice Address - Street 1:2352 MEADOWS BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80109-8406
Practice Address - Country:US
Practice Address - Phone:720-455-3879
Practice Address - Fax:720-455-3795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-03
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO19452730Medicaid
CO19452730Medicaid