Healthcare Provider Details

I. General information

NPI: 1659505139
Provider Name (Legal Business Name): FUNCTIONAL BRAIN IMAGING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2009
Last Update Date: 05/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 S YOSEMITE ST STE 280
CENTENNIAL CO
80112-2007
US

IV. Provider business mailing address

7000 S YOSEMITE ST STE 280
CENTENNIAL CO
80112-2007
US

V. Phone/Fax

Practice location:
  • Phone: 303-476-6200
  • Fax: 303-476-6201
Mailing address:
  • Phone: 303-476-6200
  • Fax: 303-476-6201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084D0003X
TaxonomyDiagnostic Neuroimaging (Psychiatry & Neurology) Physician
License Number1105-1
License Number StateCO

VIII. Authorized Official

Name: DR. STEPHEN GREGORY HIPSKIND
Title or Position: MEDICAL DIRECTOR
Credential: MD, PHD
Phone: 303-476-6200