Basic Information
| Provider Information | |||||||||
| NPI: | 1861438368 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EDWIN J. LOEFFEL JR., MD, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 RUSH DR | ||||||||
| Address2: | |||||||||
| City: | SALIDA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812019627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195308218 | ||||||||
| FaxNumber: | 9706670847 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 RUSH DR | ||||||||
| Address2: | |||||||||
| City: | SALIDA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812019627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195308218 | ||||||||
| FaxNumber: | 9706670847 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 04/27/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARCELLO | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE CONTACT | ||||||||
| AuthorizedOfficialTelephone: | 7195871213 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 01191501 | 05 | CO | MEDICAID | CG2959 | 01 | CO | RAILROAD MEDICARE | OTHER |