Provider Demographics
NPI:1356519391
Name:COLORADO ENDOSURGERY INSTITUTE, P.C.
Entity type:Organization
Organization Name:COLORADO ENDOSURGERY INSTITUTE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO AND PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:FRADKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:720-290-8772
Mailing Address - Street 1:8390 E CRESCENT PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80111-2811
Mailing Address - Country:US
Mailing Address - Phone:720-290-8772
Mailing Address - Fax:720-206-0806
Practice Address - Street 1:16830 NORTHGATE DR
Practice Address - Street 2:SUITE 130
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-5778
Practice Address - Country:US
Practice Address - Phone:720-290-8772
Practice Address - Fax:720-206-0806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO44107208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOB4195Medicare PIN