Provider Demographics
NPI:1255733374
Name:WESTERN INFECTIOUS DISEASE INFUSION CENTER, INC.
Entity type:Organization
Organization Name:WESTERN INFECTIOUS DISEASE INFUSION CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:DESJARDIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-425-9245
Mailing Address - Street 1:PO BOX 1449
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80034-1449
Mailing Address - Country:US
Mailing Address - Phone:303-425-9245
Mailing Address - Fax:303-425-1378
Practice Address - Street 1:3303 W 144TH AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80023-9464
Practice Address - Country:US
Practice Address - Phone:303-425-9245
Practice Address - Fax:303-425-1378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C377608OtherMEDICARE GROUP NUMBER