Provider Demographics
NPI:1629030689
Name:PEDIATRICS 5280 PC
Entity Type:Organization
Organization Name:PEDIATRICS 5280 PC
Other - Org Name:PEDIATRICS DTC PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:HOLBROOK
Authorized Official - Last Name:STAPP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-779-5437
Mailing Address - Street 1:9094 E MINERAL AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80112-7200
Mailing Address - Country:US
Mailing Address - Phone:303-779-5437
Mailing Address - Fax:303-689-9628
Practice Address - Street 1:9094 E MINERAL AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-7200
Practice Address - Country:US
Practice Address - Phone:303-779-5437
Practice Address - Fax:303-689-9628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO4013280Medicaid