=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689529331
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MADISON STREET PROVIDER NETWORK, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2026
-----------------------------------------------------
Last Update Date | 02/27/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 W 144TH AVE STE 110
-----------------------------------------------------
City | WESTMINSTER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80023-9326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-377-2020
-----------------------------------------------------
Fax | 303-377-2022
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 912914
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80291-2914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-377-2020
-----------------------------------------------------
Fax | 303-377-2022
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | KAREN GROSS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 303-586-9390
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------