Provider Demographics
NPI:1104001379
Name:UROLOGY OF SOUTHERN COLORADO PLLC
Entity Type:Organization
Organization Name:UROLOGY OF SOUTHERN COLORADO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:JOAN
Authorized Official - Last Name:WEAVER-OSTERHOLTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-676-3728
Mailing Address - Street 1:3676 PARKER BLVD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2212
Mailing Address - Country:US
Mailing Address - Phone:719-545-1500
Mailing Address - Fax:
Practice Address - Street 1:3676 PARKER BLVD
Practice Address - Street 2:SUITE 310
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2212
Practice Address - Country:US
Practice Address - Phone:719-545-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40134261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO48477877Medicaid
CO48477877Medicaid
COA13718Medicare UPIN