Provider Demographics
NPI:1083833834
Name:ACADEMIC NEUROLOGY & HEADACHE CLINIC PC
Entity Type:Organization
Organization Name:ACADEMIC NEUROLOGY & HEADACHE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:H
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-630-1510
Mailing Address - Street 1:2301 E PIKES PEAK AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-8006
Mailing Address - Country:US
Mailing Address - Phone:719-630-1510
Mailing Address - Fax:719-632-7343
Practice Address - Street 1:2301 E PIKES PEAK AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-8006
Practice Address - Country:US
Practice Address - Phone:719-630-1510
Practice Address - Fax:719-632-7343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO24546174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04016382Medicaid
COC71661Medicare ID - Type UnspecifiedGROUP