Healthcare Provider Details

I. General information

NPI: 1699768663
Provider Name (Legal Business Name): MADISON STREET PROVIDER NETWORK INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 MADISON ST STE 355
DENVER CO
80206-5429
US

IV. Provider business mailing address

55 MADISON ST STE 355
DENVER CO
80206-5429
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 TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: GEORGE L NEAL
Title or Position: PRESIDENT & SECRETARY
Credential:
Phone: 469-214-0144