Healthcare Provider Details

I. General information

NPI: 1891071627
Provider Name (Legal Business Name): JAYDEEP MEDICAL PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2011
Last Update Date: 10/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 EDISON ST
BRUSH CO
80723-1640
US

IV. Provider business mailing address

PO BOX 1115
FORT MORGAN CO
80701-1115
US

V. Phone/Fax

Practice location:
  • Phone: 970-842-6200
  • Fax:
Mailing address:
  • Phone: 702-453-3799
  • Fax: 702-453-5741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number47973
License Number StateCO

VIII. Authorized Official

Name: LORI LABRECQUE
Title or Position: ACCTS. MGR
Credential:
Phone: 702-453-3799