Basic Information
| Provider Information | |||||||||
| NPI: | 1437145794 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPAEDIC & SPINE CENTER OF THE ROCKIES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 E PROSPECT RD | ||||||||
| Address2: | AMBULATORY SURGERY CENTER & CONVALESCENT CARE CENTER | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805259718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704930112 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2500 E PROSPECT RD | ||||||||
| Address2: | AMBULATORY SURGERY CENTER & CONVALESCENT CARE CENTER | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805259718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704930112 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 12/16/2019 | ||||||||
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| AuthorizedOfficialLastName: | BERGERSON | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9704197005 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 12/16/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP1100X | N | Ambulatory Health Care Facilities | Clinic/Center | Podiatric | 261QP3300X | 160343 | CO | N | Ambulatory Health Care Facilities | Clinic/Center | Pain | 261QR0800X | N | Ambulatory Health Care Facilities | Clinic/Center | Recovery Care | 261QA1903X | 160343 | CO | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 261QE0800X | 160343 | CO | N | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 04510152 | 05 | CO | MEDICAID | 107463600 | 05 | WY | MEDICAID |