| Stout Street Clinic | |
|
2130 Stout St Denver CO 80205-2827 | |
| (303) 293-2220 | |
| (303) 293-6966 |
| Full Name | Stout Street Clinic |
|---|---|
| Speciality | Clinic/Center |
| Location | 2130 Stout St, Denver, Colorado |
| Authorized Official Name and Position | Pete J Stoller (CFO) |
| Authorized Official Contact | 3033129606 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Stout Street Clinic 2111 Champa St Denver CO 80205-2529 Ph: (303) 293-2217 | Stout Street Clinic 2130 Stout St Denver CO 80205-2827 Ph: (303) 293-2220 |
| NPI Number | 1396793030 |
|---|---|
| Provider Enumeration Date | 05/05/2006 |
| Last Update Date | 07/09/2021 |
| Medicare PECOS PAC ID | 7618958687 |
|---|---|
| Medicare Enrollment ID | O20040526000359 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1396793030 | NPI | - | NPPES |
| 05638390 | Medicaid | CO |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261Q00000X | Clinic/center | 1042 (Colorado) | Secondary |
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |
| Provider Name | Lia A Fiallos |
|---|---|
| Provider Type | Practitioner - General Practice |
| Provider Identifiers | NPI Number: 1861743379 PECOS PAC ID: 1658684352 Enrollment ID: I20150827003198 |
| Provider Name | Charles Lutz-priefert |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1639545312 PECOS PAC ID: 9931505047 Enrollment ID: I20210914003264 |
| Provider Name | Kandice Nichole Eakes |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1760770358 PECOS PAC ID: 8022283993 Enrollment ID: I20220804003237 |
| Provider Name | Karen L Spring |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1871730093 PECOS PAC ID: 5698822385 Enrollment ID: I20220805001318 |
| Provider Name | Kristin N Pashia |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1811579360 PECOS PAC ID: 6608275276 Enrollment ID: I20220826000669 |
| Provider Name | Ronald J Meyer |
|---|---|
| Provider Type | Practitioner - Other (non-physician) |
| Provider Identifiers | NPI Number: 1003111832 PECOS PAC ID: 5294185245 Enrollment ID: I20240103001513 |
| Provider Name | Thomas Sean O'toole |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1548732209 PECOS PAC ID: 7517318272 Enrollment ID: I20240105004023 |
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