Basic Information
| Provider Information | |||||||||
| NPI: | 1285619759 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAROLLO | ||||||||
| FirstName: | BERT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 S CASCADE AVE STE 140 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809031604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7198666568 | ||||||||
| FaxNumber: | 7195382999 | ||||||||
| Practice Location | |||||||||
| Address1: | 1633 MEDICAL CENTER PT | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196674139 | ||||||||
| FaxNumber: | 7194738843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2005 | ||||||||
| LastUpdateDate: | 06/11/2018 | ||||||||
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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 | 2085R0202X | DR.0030072 | CO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 01300722 | 05 | CO | MEDICAID |