Provider Demographics
NPI:1538152442
Name:ROCKY MOUNTAIN PEDIATRICS PC
Entity type:Organization
Organization Name:ROCKY MOUNTAIN PEDIATRICS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDRA
Authorized Official - Middle Name:B
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-233-8701
Mailing Address - Street 1:2020 WADSWORTH BLVD
Mailing Address - Street 2:SUITE 16
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80214-5730
Mailing Address - Country:US
Mailing Address - Phone:303-233-8701
Mailing Address - Fax:303-233-2850
Practice Address - Street 1:2020 WADSWORTH BLVD
Practice Address - Street 2:SUITE 16
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80214-5730
Practice Address - Country:US
Practice Address - Phone:303-233-8701
Practice Address - Fax:303-233-2850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-25
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04001855Medicaid
CO04001855Medicaid