Healthcare Provider Details

I. General information

NPI: 1487026951
Provider Name (Legal Business Name): SURGICAL SPECIALISTS OF COLORADO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2015
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10103 RIDGEGATE PKWY STE 309
LONE TREE CO
80124-5525
US

IV. Provider business mailing address

14100 E ARAPAHOE RD STE 260
CENTENNIAL CO
80112-4048
US

V. Phone/Fax

Practice location:
  • Phone: 720-616-7835
  • Fax: 303-736-4226
Mailing address:
  • Phone: 720-616-7835
  • Fax: 303-736-4226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberDR47517
License Number StateCO

VIII. Authorized Official

Name: JACQUELYN KAY GLENN
Title or Position: OWNER/OPERATOR
Credential:
Phone: 720-820-9455