Basic Information
| Provider Information | |||||||||
| NPI: | 1891729117 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAGE | ||||||||
| FirstName: | CLARICE | ||||||||
| MiddleName: | BERNADETTE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 S PARK AVE | ||||||||
| Address2: | |||||||||
| City: | BRECKENRIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804246347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704531010 | ||||||||
| FaxNumber: | 9704535407 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 S PARK AVE | ||||||||
| Address2: | |||||||||
| City: | BRECKENRIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804246347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704531010 | ||||||||
| FaxNumber: | 9704535407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 07/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | DR.0044434 | CO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 81452039 | 05 | CO | MEDICAID |