Provider Demographics
NPI:1972733004
Name:HEALTHONE HIGH STREET PRIMARY CARE
Entity Type:Organization
Organization Name:HEALTHONE HIGH STREET PRIMARY CARE
Other - Org Name:HEALTHONE HIGH STREET PRIMARY CARE CENTER LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DWINNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-869-2160
Mailing Address - Street 1:1721 E 19TH AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80218-1251
Mailing Address - Country:US
Mailing Address - Phone:303-869-2160
Mailing Address - Fax:303-869-2544
Practice Address - Street 1:1721 E 19TH AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1251
Practice Address - Country:US
Practice Address - Phone:303-869-2160
Practice Address - Fax:303-869-2544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-23
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO26186207R00000X, 207RA0000X, 207RE0101X, 207V00000X, 207VG0400X, 208000000X, 2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO49280732Medicaid
CO49280732Medicaid