Basic Information
| Provider Information | |||||||||
| NPI: | 1821159807 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROSS E. DICKSTEIN MDPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2044 | ||||||||
| Address2: | |||||||||
| City: | SILVERTHORNE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804982044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034229438 | ||||||||
| FaxNumber: | 3034229474 | ||||||||
| Practice Location | |||||||||
| Address1: | 340 PEAK ONE SURGERY CENTER | ||||||||
| Address2: | COUNTY R | ||||||||
| City: | FRISCO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034229438 | ||||||||
| FaxNumber: | 3034229474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | DICKSTEIN | ||||||||
| AuthorizedOfficialFirstName: | ROSS | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3034229438 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 37335 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | DE1868 | 01 | CO | RAILROAD MEDICARE | OTHER |