Provider Demographics
NPI:1043295355
Name:EAR NOSE AND THROAT OF COLORADO SPRINGS PC
Entity Type:Organization
Organization Name:EAR NOSE AND THROAT OF COLORADO SPRINGS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DALSASO
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:719-632-5020
Mailing Address - Street 1:2403 N UNION BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-1185
Mailing Address - Country:US
Mailing Address - Phone:712-963-2502
Mailing Address - Fax:
Practice Address - Street 1:2403 N UNION BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1185
Practice Address - Country:US
Practice Address - Phone:712-963-2502
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16439207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01164391Medicaid
COC342208Medicare PIN