Provider Demographics
NPI:1699768663
Name:MADISON STREET PROVIDER NETWORK INC
Entity type:Organization
Organization Name:MADISON STREET PROVIDER NETWORK INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:L
Authorized Official - Last Name:NEAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-214-0144
Mailing Address - Street 1:55 MADISON ST STE 355
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-5429
Mailing Address - Country:US
Mailing Address - Phone:303-377-2020
Mailing Address - Fax:303-377-2022
Practice Address - Street 1:55 MADISON ST STE 355
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-5429
Practice Address - Country:US
Practice Address - Phone:303-377-2020
Practice Address - Fax:303-377-2022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-25
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO152W00000X, 152W00000X
207W00000X
CO24332174400000X
CO40750174400000X
CO41566174400000X
CO13970174400000X
CO43717174400000X
CO40364174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04012274Medicaid
CO12832278Medicaid
CO6151070001Medicare NSC
CO04012274Medicaid