Provider Demographics
NPI:1639207095
Name:DIVERSIFIED RADIOLOGY OF COLORADO, PC
Entity Type:Organization
Organization Name:DIVERSIFIED RADIOLOGY OF COLORADO, PC
Other - Org Name:INTERVENTIONAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMILLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-914-8800
Mailing Address - Street 1:938 BANNOCK ST
Mailing Address - Street 2:STE 300
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204-4028
Mailing Address - Country:US
Mailing Address - Phone:303-914-8800
Mailing Address - Fax:
Practice Address - Street 1:1601 E 19TH AVE
Practice Address - Street 2:STE 3850
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1216
Practice Address - Country:US
Practice Address - Phone:303-226-7225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04004826Medicaid
CO04004826Medicaid