# PARK AVENUE SURGERY CENTER LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1154328508
- **Authorized official:** DR. JERRY KIRK POPHAM M.D. (PHYSICIAN)
- **Authorized official phone:** (303) 468-8844

## Contact information

- **Practice address:** 1800 EMERSON ST, \#220, DENVER, CO 80218-1014
- **Practice address phone:** (303) 468-8844
- **Practice address fax:** (303) 468-8850
- **Mailing address:** 1800 EMERSON ST, \#200, DENVER, CO 80218-1014
- **Mailing address phone:** (303) 468-8844
- **Mailing address fax:** (303) 468-8850

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QA1903X | Ambulatory Surgical Clinic/Center | 0471 | CO | Yes |

## Other

- **Enumeration date:** 06/30/2005
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 0471 | STATE LICENSE | CO |