Provider Demographics
NPI:1053928234
Name:COLORADO MEDICAL GROUP, PLLC
Entity type:Organization
Organization Name:COLORADO MEDICAL GROUP, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-867-0606
Mailing Address - Street 1:3810 NORTHDALE BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-1871
Mailing Address - Country:US
Mailing Address - Phone:813-961-1331
Mailing Address - Fax:888-850-8316
Practice Address - Street 1:3535 S LAFAYETTE ST STE 100
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-3954
Practice Address - Country:US
Practice Address - Phone:800-991-6117
Practice Address - Fax:888-812-8191
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLORADO MEDICAL GROUP, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-30
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty