Basic Information
| Provider Information | |||||||||
| NPI: | 1538474739 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRINCIPLED SERVICE INTERNAL MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64018 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809624018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193298616 | ||||||||
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| Practice Location | |||||||||
| Address1: | 615 FAIRHURST ST | ||||||||
| Address2: | |||||||||
| City: | STERLING | ||||||||
| State: | CO | ||||||||
| PostalCode: | 807514523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705220122 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2010 | ||||||||
| LastUpdateDate: | 04/28/2015 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | MARVIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN / OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7193298616 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 43946 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.