Provider Demographics
NPI:1164564928
Name:SHRIVER, PHILLIP AUDRA (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:AUDRA
Last Name:SHRIVER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 PRINTERS PKWY
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-3190
Mailing Address - Country:US
Mailing Address - Phone:719-632-5700
Mailing Address - Fax:
Practice Address - Street 1:2880 INTERNATIONAL CIR # N010
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3127
Practice Address - Country:US
Practice Address - Phone:719-520-7080
Practice Address - Fax:719-520-7086
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO42075207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO35001577Medicaid
COCO300624Medicare PIN
CO35001577Medicaid
COCO300344Medicare PIN