Provider Demographics
NPI:1104157775
Name:PORTERCARE ADVENTIST HEALTH SYSTEM
Entity type:Organization
Organization Name:PORTERCARE ADVENTIST HEALTH SYSTEM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:C.M.O.
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-673-7181
Mailing Address - Street 1:PO BOX 911244
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-1244
Mailing Address - Country:US
Mailing Address - Phone:303-643-1099
Mailing Address - Fax:303-643-1176
Practice Address - Street 1:9399 CROWN CREST BLVD
Practice Address - Street 2:SUITE 401
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80138-8506
Practice Address - Country:US
Practice Address - Phone:720-274-2544
Practice Address - Fax:720-274-2541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-21
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO80353568Medicaid
CO20422571Medicaid
CO80353568Medicaid