Healthcare Provider Details

I. General information

NPI: 1891294922
Provider Name (Legal Business Name): EDMUND SURGICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2018
Last Update Date: 08/18/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1079 JOLIET ST
AURORA CO
80010-4047
US

IV. Provider business mailing address

1079 JOLIET ST
AURORA CO
80010-4047
US

V. Phone/Fax

Practice location:
  • Phone: 303-815-4708
  • Fax:
Mailing address:
  • Phone: 303-815-4708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA.0001568
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: DENNIS E PAIGE
Title or Position: SURGICAL ASSISTANT
Credential:
Phone: 303-815-4708