Healthcare Provider Details

I. General information

NPI: 1306233788
Provider Name (Legal Business Name): OPTUMCARE COLORADO SPRINGS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2015
Last Update Date: 08/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 N NEVADA AVE STE 4001
COLORADO SPRINGS CO
80907
US

IV. Provider business mailing address

2 S. CASCADE AVE SUITE 140
COLORADO SPRINGS CO
80903-1653
US

V. Phone/Fax

Practice location:
  • Phone: 719-636-9393
  • Fax: 719-636-9087
Mailing address:
  • Phone: 719-538-2900
  • Fax: 719-538-2987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number
License Number StateCO
# 6
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number StateCO

VIII. Authorized Official

Name: JOHN G. LIETHEN
Title or Position: SECRETARY
Credential:
Phone: 952-205-6262