Provider Demographics
NPI:1629262217
Name:ELENA M CHEBANOVA, MD, PC
Entity Type:Organization
Organization Name:ELENA M CHEBANOVA, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:MS
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CHEBANOVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-696-1395
Mailing Address - Street 1:9450 E MISSISSIPPI AVE # B
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-2307
Mailing Address - Country:US
Mailing Address - Phone:303-696-1395
Mailing Address - Fax:303-696-1606
Practice Address - Street 1:9450 E MISSISSIPPI AVE # B
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80247-2307
Practice Address - Country:US
Practice Address - Phone:303-696-1395
Practice Address - Fax:303-696-1606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO35300261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04021796Medicaid
COC17631OtherMEDICARE
COBC4939053OtherDEA
COBC4939053OtherDEA