Basic Information
| Provider Information | |||||||||
| NPI: | 1669478541 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERARDUCCI | ||||||||
| FirstName: | LAURENCE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3670 PARKER BLVD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810082285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195641544 | ||||||||
| FaxNumber: | 7199241593 | ||||||||
| Practice Location | |||||||||
| Address1: | 3670 PARKER BLVD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810082285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195641544 | ||||||||
| FaxNumber: | 7199241593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2005 | ||||||||
| LastUpdateDate: | 07/22/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 102133 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 51214 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | P01102505 | 01 | CO | RAILROAD MEDICARE | OTHER | 39223361 | 05 | CO | MEDICAID |