Basic Information
| Provider Information | |||||||||
| NPI: | 1720060437 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLORADO SPRINGS IMAGING LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8610 EXPLORER DR | ||||||||
| Address2: | 300 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809201058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7199554140 | ||||||||
| FaxNumber: | 7199554148 | ||||||||
| Practice Location | |||||||||
| Address1: | 6005 DELMONICO DR | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809192237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192606500 | ||||||||
| FaxNumber: | 7192607750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2005 | ||||||||
| LastUpdateDate: | 05/11/2015 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
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| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 7199554332 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 05070571 | 05 | CO | MEDICAID |