Provider Demographics
NPI:1124216940
Name:SCOT F. SICKBERT, M.D., LLC
Entity Type:Organization
Organization Name:SCOT F. SICKBERT, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOT
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:SICKBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-761-0397
Mailing Address - Street 1:325 PARKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-3134
Mailing Address - Country:US
Mailing Address - Phone:719-761-0397
Mailing Address - Fax:719-473-7475
Practice Address - Street 1:325 PARKSIDE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3134
Practice Address - Country:US
Practice Address - Phone:719-761-0397
Practice Address - Fax:719-473-7475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO25001207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO68902573Medicaid
CO68902573Medicaid