Basic Information
| Provider Information | |||||||||
| NPI: | 1134104441 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FACIAL PLASTIC SURGERY CENTER OF COLORADO SPRINGS, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 ELM AVE STE 103 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809063130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706632742 | ||||||||
| FaxNumber: | 9703422093 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 ELM AVE STE 150 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809063131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196325020 | ||||||||
| FaxNumber: | 1952054887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2005 | ||||||||
| LastUpdateDate: | 11/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | DALSASO | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | ANDREW | ||||||||
| AuthorizedOfficialTitleorPosition: | ONWER | ||||||||
| AuthorizedOfficialTelephone: | 7196325020 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 37351 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 39155285 | 05 | CO | MEDICAID |