Provider Demographics
NPI:1861691719
Name:WESTERN MEDICAL CENTER PC
Entity type:Organization
Organization Name:WESTERN MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR STAFF PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:MANNING
Authorized Official - Last Name:PICKETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-232-3232
Mailing Address - Street 1:1805 KIPLING ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80215
Mailing Address - Country:US
Mailing Address - Phone:303-232-3232
Mailing Address - Fax:303-232-8922
Practice Address - Street 1:1805 KIPLING ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80215
Practice Address - Country:US
Practice Address - Phone:303-232-3232
Practice Address - Fax:303-232-3232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18721207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04004966Medicaid
COA6908Medicare UPIN