Provider Demographics
NPI:1063167211
Name:BIG TREE MEDICAL GROUP LLC
Entity type:Organization
Organization Name:BIG TREE MEDICAL GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRIMARY PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTONY
Authorized Official - Middle Name:NGUYEN
Authorized Official - Last Name:VANBANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:720-323-0621
Mailing Address - Street 1:1701 S FEDERAL BLVD
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80219-4898
Mailing Address - Country:US
Mailing Address - Phone:720-323-0621
Mailing Address - Fax:303-934-4036
Practice Address - Street 1:1701 S FEDERAL BLVD
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80219-4898
Practice Address - Country:US
Practice Address - Phone:720-323-0621
Practice Address - Fax:303-934-4036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-16
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CODR.0054747OtherCOLORADO DEPARTMENT OF REGULATORY AGENCIES DIVISION OF PROFESSIONS AND OCCUPATIO