Provider Demographics
NPI:1316108459
Name:STADIUM MEDICAL, INC.
Entity type:Organization
Organization Name:STADIUM MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:BERNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:AMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-549-7916
Mailing Address - Street 1:695 CANOSA CT
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204-4143
Mailing Address - Country:US
Mailing Address - Phone:720-630-2000
Mailing Address - Fax:
Practice Address - Street 1:695 CANOSA CT
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-4143
Practice Address - Country:US
Practice Address - Phone:720-630-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-20
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO06-74293416L0300X
341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO12959049Medicaid
C501278Medicare PIN