Provider Demographics
NPI:1710910823
Name:SOUTH DENVER NEPHROLOGY ASSOCIATES PLLC
Entity Type:Organization
Organization Name:SOUTH DENVER NEPHROLOGY ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:DILLINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-891-0977
Mailing Address - Street 1:950 E HARVARD AVE
Mailing Address - Street 2:SUITE 240
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-7006
Mailing Address - Country:US
Mailing Address - Phone:303-871-0977
Mailing Address - Fax:303-733-2387
Practice Address - Street 1:950 E HARVARD AVE
Practice Address - Street 2:SUITE 240
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210-7006
Practice Address - Country:US
Practice Address - Phone:303-871-0977
Practice Address - Fax:303-733-2387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RN0300X
CO23200207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04015087Medicaid
COCA1508Medicare PIN