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NPI Code Detail

MEDICARE: PORTERCARE ADVENTIST HEALTH SYSTEM

MEDICARE: PORTERCARE ADVENTIST HEALTH SYSTEM
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1208800000XUrology Physician

General Provider Information

NPI Number : 1942165626
Entity Type Code : Organization
Provider Name (Legal Business Name) : PORTERCARE ADVENTIST HEALTH SYSTEM
Provider Business Mailing Address
First Line : PO BOX 713425
Second Line :
City : CHICAGO
State : IL
Zip : 60677-4325
Country : US
Telephone Number : 800-953-0104
Fax Number :
Provider Business Practice Location Address
First Line : 12596 W BAYAUD AVE STE 100
Second Line :
City : LAKEWOOD
State : CO
Zip : 80228-2035
Country : US
Telephone Number : 303-825-8822
Fax Number : 303-825-4022
Authorized Official
Title or Position : COO
Name : JASON TACHA
Credential :
Telephone Number : 303-304-7752
Provider Enumeration Date : 12/16/2025
Last Update Date : 12/16/2025

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1962243444 — NICOLE TUCKER PA-C
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1750119913 — YULIYA MEZENTSEVA
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1427881598 — PORTERCARE ADVENTIST HEALTH SYSTEM
Practice Location Address:
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Directions to “PORTERCARE ADVENTIST HEALTH SYSTEM ” Practice Location

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