Provider Demographics
NPI:1134104441
Name:FACIAL PLASTIC SURGERY CENTER OF COLORADO SPRINGS, PC
Entity Type:Organization
Organization Name:FACIAL PLASTIC SURGERY CENTER OF COLORADO SPRINGS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ONWER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:DALSASO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-632-5020
Mailing Address - Street 1:6 ELM AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3130
Mailing Address - Country:US
Mailing Address - Phone:970-663-2742
Mailing Address - Fax:970-342-2093
Practice Address - Street 1:6 ELM AVE STE 150
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3131
Practice Address - Country:US
Practice Address - Phone:719-632-5020
Practice Address - Fax:195-205-4887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO37351208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO39155285Medicaid
CO39155285Medicaid