Basic Information
| Provider Information | |||||||||
| NPI: | 1871576512 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED GYNECOLOGY PROF, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5731 SILVERSTONE TER STE 250 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809193545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196338773 | ||||||||
| FaxNumber: | 7196331905 | ||||||||
| Practice Location | |||||||||
| Address1: | 5731 SILVERSTONE TER STE 250 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809193545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196338773 | ||||||||
| FaxNumber: | 7196331905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2005 | ||||||||
| LastUpdateDate: | 04/05/2021 | ||||||||
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| AuthorizedOfficialLastName: | STRINGFELLOW | ||||||||
| AuthorizedOfficialFirstName: | ROY | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7196338773 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 41885244 | 05 | CO | MEDICAID |