Provider Demographics
NPI:1235353087
Name:PEDIATRIC AND ADOLESCENT CENTER
Entity type:Organization
Organization Name:PEDIATRIC AND ADOLESCENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:L
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-758-0005
Mailing Address - Street 1:3400 S ONEIDA WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80224-2850
Mailing Address - Country:US
Mailing Address - Phone:303-758-0005
Mailing Address - Fax:303-756-8077
Practice Address - Street 1:3400 S ONEIDA WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80224-2850
Practice Address - Country:US
Practice Address - Phone:303-758-0005
Practice Address - Fax:303-756-8077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO121002080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO99173824Medicaid