=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942605761
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLORADO PHYSICIANS HEALTH ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2014
-----------------------------------------------------
Last Update Date | 01/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5340 S QUEBEC ST SUITE 210-D
-----------------------------------------------------
City | GREENWOOD VILLAGE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80111-1909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-359-7980
-----------------------------------------------------
Fax | 719-260-5921
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5340 S QUEBEC ST SUITE 210-D
-----------------------------------------------------
City | GREENWOOD VILLAGE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80111-1909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-359-7980
-----------------------------------------------------
Fax | 719-260-5921
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MARVIN L SWANSON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 720-359-7980
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | DR0018703
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------