Provider Demographics
NPI:1043633647
Name:PEDIATRIC AND ADOLESCENT MEDICINE ASSOCIATES PC
Entity type:Organization
Organization Name:PEDIATRIC AND ADOLESCENT MEDICINE ASSOCIATES PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENTT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:B
Authorized Official - Last Name:ROOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-695-7667
Mailing Address - Street 1:9235 CROWN CREST BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80138-8880
Mailing Address - Country:US
Mailing Address - Phone:303-695-7667
Mailing Address - Fax:303-695-8146
Practice Address - Street 1:9235 CROWN CREST BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80138-8880
Practice Address - Country:US
Practice Address - Phone:303-695-7667
Practice Address - Fax:303-695-8146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO433261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04009304Medicaid