Provider Demographics
NPI:1013678879
Name:MOUNTAIN BLUE CANCER CARE CENTER
Entity Type:Organization
Organization Name:MOUNTAIN BLUE CANCER CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:WITTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-870-3293
Mailing Address - Street 1:4747 S DOWNING ST
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-5917
Mailing Address - Country:US
Mailing Address - Phone:303-999-6745
Mailing Address - Fax:303-586-2228
Practice Address - Street 1:3501 S CORONA ST STE 1
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-3907
Practice Address - Country:US
Practice Address - Phone:303-999-6745
Practice Address - Fax:303-586-2228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-04
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO82076529Medicaid