Provider Demographics
NPI:1689839144
Name:EVERGREEN PEDIATRICS, LLC
Entity Type:Organization
Organization Name:EVERGREEN PEDIATRICS, LLC
Other - Org Name:EVERGREEN CONIFER PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:KUTALEK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-674-6671
Mailing Address - Street 1:30960 STAGECOACH BLVD
Mailing Address - Street 2:SUITE W-120
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-7902
Mailing Address - Country:US
Mailing Address - Phone:303-674-6671
Mailing Address - Fax:303-674-0031
Practice Address - Street 1:30960 STAGECOACH BLVD
Practice Address - Street 2:SUITE W-120
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-7902
Practice Address - Country:US
Practice Address - Phone:303-674-6671
Practice Address - Fax:303-674-0031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO26133208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01261338Medicaid
CO04007977Medicaid
CO40308332Medicaid
CO04007977Medicaid
CO40308332Medicaid