Provider Demographics
NPI:1144763251
Name:PEAK NEUROLOGY CORP PC
Entity Type:Organization
Organization Name:PEAK NEUROLOGY CORP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIEBE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:719-445-9902
Mailing Address - Street 1:13010 TAHOSA LN
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80908-3251
Mailing Address - Country:US
Mailing Address - Phone:269-209-7019
Mailing Address - Fax:
Practice Address - Street 1:5770 FLINTRIDGE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-1881
Practice Address - Country:US
Practice Address - Phone:719-445-9902
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-21
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2084N0400X
CODR.0054025261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000149974Medicaid