Provider Demographics
NPI:1891793022
Name:INTERMOUNTAIN ANESTHESIA PROFESSIONAL CONSULTANTS, LLP
Entity Type:Organization
Organization Name:INTERMOUNTAIN ANESTHESIA PROFESSIONAL CONSULTANTS, LLP
Other - Org Name:NORTHERN COLORADO PAIN MANAGEMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLESPIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-495-0300
Mailing Address - Street 1:1175 58TH AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-4807
Mailing Address - Country:US
Mailing Address - Phone:970-495-0300
Mailing Address - Fax:970-224-9624
Practice Address - Street 1:1175 58TH AVE
Practice Address - Street 2:STE 202
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-4807
Practice Address - Country:US
Practice Address - Phone:970-495-0300
Practice Address - Fax:970-224-9624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO207L00000X
207L00000X, 207VG0400X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COIM160808OtherANTHEM BCBS
WY112073500Medicaid
CO04018909Medicaid
CO04018909Medicaid
COIM160808OtherANTHEM BCBS
WY112073500Medicaid
CI4501Medicare PIN