Basic Information
| Provider Information | |||||||||
| NPI: | 1972980027 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CEDAR SPRINGS HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CEDAR SPRINGS HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2135 SOUTHGATE RD | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809062605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193295350 | ||||||||
| FaxNumber: | 7195785407 | ||||||||
| Practice Location | |||||||||
| Address1: | 2135 SOUTHGATE RD | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809062605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193295350 | ||||||||
| FaxNumber: | 7195785407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2015 | ||||||||
| LastUpdateDate: | 04/28/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MASSINGILL | ||||||||
| AuthorizedOfficialFirstName: | DOUG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PHARMACY | ||||||||
| AuthorizedOfficialTelephone: | 7192008091 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0002X | PDO0240000009 | CO | Y | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2151303 | 01 | PK | OTHER |