Provider Demographics
NPI:1548479793
Name:WESTERN NEUROLOGICAL GROUP, P.C.
Entity type:Organization
Organization Name:WESTERN NEUROLOGICAL GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERSONNEL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-839-6279
Mailing Address - Street 1:1601 E 19TH AVE
Mailing Address - Street 2:SUITE 4400
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80218-1216
Mailing Address - Country:US
Mailing Address - Phone:303-861-2266
Mailing Address - Fax:303-830-7054
Practice Address - Street 1:1601 E 19TH AVE
Practice Address - Street 2:SUITE 4400
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1216
Practice Address - Country:US
Practice Address - Phone:303-861-2266
Practice Address - Fax:303-830-7054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO33002174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04006185Medicaid
COD24678Medicare UPIN
COCP7008Medicare ID - Type Unspecified
COE79773Medicare UPIN