Basic Information
| Provider Information | |||||||||
| NPI: | 1326229527 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN COLORADO UROLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 549 | ||||||||
| Address2: | |||||||||
| City: | SALIDA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812010549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195302000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 550 W HWY 50 | ||||||||
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| City: | SALIDA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812012238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195302000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2007 | ||||||||
| LastUpdateDate: | 11/16/2007 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | VICKY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7195302016 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 17434 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 01174341 | 05 | CO | MEDICAID |