Basic Information
| Provider Information | |||||||||
| NPI: | 1245201797 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CIEZKI | ||||||||
| FirstName: | MARY ELIZABETH | ||||||||
| MiddleName: | |||||||||
| 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: | 7194759800 | ||||||||
| FaxNumber: | 7194735436 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2006 | ||||||||
| LastUpdateDate: | 08/06/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 40061 | CO | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 61522848 | 05 | CO | MEDICAID |