Provider Demographics
NPI:1689042939
Name:SURGICAL SPECIALISTS OF COLORADO PLLC
Entity type:Organization
Organization Name:SURGICAL SPECIALISTS OF COLORADO PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:720-820-9455
Mailing Address - Street 1:10103 RIDGEGATE PKWY STE 211
Mailing Address - Street 2:
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-5525
Mailing Address - Country:US
Mailing Address - Phone:720-820-9455
Mailing Address - Fax:303-736-4226
Practice Address - Street 1:10103 RIDGEGATE PKWY STE 211
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-5525
Practice Address - Country:US
Practice Address - Phone:720-820-9455
Practice Address - Fax:303-736-4226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-03
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO47517208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000171312Medicaid