Basic Information
| Provider Information | |||||||||
| NPI: | 1770579385 | ||||||||
| 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: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805259718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704930112 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2500 E PROSPECT RD | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805259718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704930112 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 12/30/2019 | ||||||||
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| AuthorizedOfficialLastName: | BERGERSON | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9704197005 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 12/30/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 213ES0103X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 335E00000X | N | Suppliers | Prosthetic/Orthotic Supplier | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 04640082 | 05 | CO | MEDICAID | CS8670 | 01 | CO | RR MEDICARE | OTHER | 107463601 | 05 | WY | MEDICAID |