Basic Information
| Provider Information | |||||||||
| NPI: | 1144225624 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UROLOGY CONSULTANTS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4100 JERRY MURPHY RD | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810011076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195459713 | ||||||||
| FaxNumber: | 7195452054 | ||||||||
| Practice Location | |||||||||
| Address1: | 4100 JERRY MURPHY RD | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810011076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195459713 | ||||||||
| FaxNumber: | 7195452054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 08/24/2011 | ||||||||
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| AuthorizedOfficialLastName: | BICKEL | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
| AuthorizedOfficialMiddleName: | WYCHE | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7195459713 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | RU608163 | 01 | CO | BLUE CROSS BLUE SHIELD | OTHER | 77878272 | 05 | CO | MEDICAID |