Basic Information
| Provider Information | |||||||||
| NPI: | 1053799171 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUE SAGE MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3107 W COLORADO AVE | ||||||||
| Address2: | BOX 291 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809042088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024533799 | ||||||||
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| Practice Location | |||||||||
| Address1: | 615 FAIRHURST ST | ||||||||
| Address2: | |||||||||
| City: | STERLING | ||||||||
| State: | CO | ||||||||
| PostalCode: | 807514523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705220122 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2015 | ||||||||
| LastUpdateDate: | 05/08/2015 | ||||||||
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| AuthorizedOfficialLastName: | LABRECQUE | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
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| AuthorizedOfficialTitleorPosition: | ACCOUNTS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7024533799 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | DR30054726 | CO | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | DR30054726 | CO | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | DR30054726 | 01 | CO | CO LICENSE | OTHER | M12236 | 01 | ID | ID LICENSE | OTHER |