Basic Information
| Provider Information | |||||||||
| NPI: | 1184695645 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNER | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | MARC | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 S CASCADE AVE | ||||||||
| Address2: | 140 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809031624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195382950 | ||||||||
| FaxNumber: | 7195382996 | ||||||||
| Practice Location | |||||||||
| Address1: | 1633 MEDICAL CENTER PT | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809075700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194471000 | ||||||||
| FaxNumber: | 7194718841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2006 | ||||||||
| LastUpdateDate: | 08/06/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 594 | CO | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 72755718 | 05 | CO | MEDICAID |