Basic Information
| Provider Information | |||||||||
| NPI: | 1134643604 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLINICAL COLLEAGUES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CLINICAL COLLEAGUES INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 824246 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191824246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545700337 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2100 W SUNSET DR | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825012274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004943964 | ||||||||
| FaxNumber: | 9545700317 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2017 | ||||||||
| LastUpdateDate: | 08/11/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GERDES | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8004943964 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CLINICAL COLLEAGUES INC | ||||||||
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| NPICertificationDate: | 08/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.