Provider Demographics
NPI:1962726927
Name:PORTERCARE ADVENTIST HEALTH SYSTEM
Entity type:Organization
Organization Name:PORTERCARE ADVENTIST HEALTH SYSTEM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OMA ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:SKINNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-673-7175
Mailing Address - Street 1:PO BOX 911244
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-1244
Mailing Address - Country:US
Mailing Address - Phone:303-643-1099
Mailing Address - Fax:303-643-1176
Practice Address - Street 1:805 S BROADWAY ST
Practice Address - Street 2:SUITE 103
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-5971
Practice Address - Country:US
Practice Address - Phone:303-269-2560
Practice Address - Fax:303-494-1841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-19
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO98209574Medicaid
COC453748Medicare PIN