Provider Demographics
NPI:1215171434
Name:BLUE SKY OUTPATIENT NEUROLOGY, LLC
Entity type:Organization
Organization Name:BLUE SKY OUTPATIENT NEUROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:IRA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-781-4485
Mailing Address - Street 1:499 E HAMPDEN AVE
Mailing Address - Street 2:SUITE 360
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-2780
Mailing Address - Country:US
Mailing Address - Phone:303-781-4485
Mailing Address - Fax:720-274-0064
Practice Address - Street 1:499 E HAMPDEN AVE
Practice Address - Street 2:SUITE 360
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-2780
Practice Address - Country:US
Practice Address - Phone:303-781-4485
Practice Address - Fax:720-274-0064
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLUE SKY NEUROSCIENCES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-01
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO80634273Medicaid
CO80634273Medicaid