Healthcare Provider Details

I. General information

NPI: 1932054681
Provider Name (Legal Business Name): MADISON STREET PROVIDER NETWORK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2026
Last Update Date: 02/27/2026
Certification Date: 02/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 S POTOMAC ST STE 130
AURORA CO
80012-4511
US

IV. Provider business mailing address

PO BOX 912914
DENVER CO
80291-2914
US

V. Phone/Fax

Practice location:
  • Phone: 303-377-2020
  • Fax: 303-377-2022
Mailing address:
  • Phone: 303-377-2020
  • Fax: 303-377-2022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: KAREN GROSS
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 303-586-9390