Provider Demographics
NPI:1134149594
Name:COLORADO HEART CLINIC PROFESSIONAL LLC
Entity type:Organization
Organization Name:COLORADO HEART CLINIC PROFESSIONAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSURANCE BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:S
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-778-1171
Mailing Address - Street 1:850 E HARVARD AVE
Mailing Address - Street 2:STE 365
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-5076
Mailing Address - Country:US
Mailing Address - Phone:303-778-1171
Mailing Address - Fax:303-778-1674
Practice Address - Street 1:850 E HARVARD AVE
Practice Address - Street 2:STE 365
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210-5076
Practice Address - Country:US
Practice Address - Phone:303-778-1171
Practice Address - Fax:303-778-1674
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLORADO HEART CLINIC PROFESSIONAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-20
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO41162207RC0000X
CO41133207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO41162OtherDR TRACY PAESCHKE
CO41133OtherDR VITO CALANDRO
CO95178732Medicaid
CO11827238Medicaid
CO41133OtherDR VITO CALANDRO
CO95178732Medicaid
COC486258Medicare PIN