Basic Information
| Provider Information | |||||||||
| NPI: | 1295783876 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER ORTHOPEDICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3920 N UNION BLVD | ||||||||
| Address2: | STE 330 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809074916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195707272 | ||||||||
| FaxNumber: | 7195709030 | ||||||||
| Practice Location | |||||||||
| Address1: | 3920 N UNION BLVD | ||||||||
| Address2: | STE 330 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809074916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195707272 | ||||||||
| FaxNumber: | 7195709030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 04/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | WALDEN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7195707272 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 04009056 | 05 | CO | MEDICAID | PRJ3008 | 01 | CO | BLUE SHIELD GROUP ID | OTHER |