Provider Demographics
NPI:1053463836
Name:SOUTHERN COLORADO VASCULAR SURGERY PC
Entity Type:Organization
Organization Name:SOUTHERN COLORADO VASCULAR SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:MISARE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-630-3465
Mailing Address - Street 1:2960 N CIRCLE DR STE 115
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-1163
Mailing Address - Country:US
Mailing Address - Phone:719-630-3465
Mailing Address - Fax:719-630-3476
Practice Address - Street 1:2960 N CIRCLE DR STE 115
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1163
Practice Address - Country:US
Practice Address - Phone:719-630-3465
Practice Address - Fax:719-630-3476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO38531174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO36589365Medicaid
CO508008Medicare ID - Type Unspecified