Basic Information
| Provider Information | |||||||||
| NPI: | 1306826482 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PIKES PEAK RADIATION ONCOLOGY P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1425 N UNION BLVD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809092871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195707675 | ||||||||
| FaxNumber: | 7194719314 | ||||||||
| Practice Location | |||||||||
| Address1: | 1425 N UNION BLVD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809092871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195707675 | ||||||||
| FaxNumber: | 7194719314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HAZUKA | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7195707675 | ||||||||
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| 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 | 2085R0001X | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 04017968 | 05 | CO | MEDICAID | 40421 | 01 | CO | BCBS | OTHER |