Provider Demographics
NPI:1144252602
Name:DOUGLAS MEDICAL PC
Entity type:Organization
Organization Name:DOUGLAS MEDICAL PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:K
Authorized Official - Last Name:ENGLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-688-6900
Mailing Address - Street 1:410 S WILCOX ST
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-2662
Mailing Address - Country:US
Mailing Address - Phone:303-688-6900
Mailing Address - Fax:303-688-1417
Practice Address - Street 1:410 S WILCOX ST
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-2662
Practice Address - Country:US
Practice Address - Phone:303-688-6900
Practice Address - Fax:303-688-1417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16446207QS0010X, 208000000X, 207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04007407Medicaid
COC64204Medicare PIN
CO1074170001Medicare NSC