Provider Demographics
NPI:1184224461
Name:PIKES PEAK NEPHROLOGY ASSOCIATES PC
Entity Type:Organization
Organization Name:PIKES PEAK NEPHROLOGY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JEANINE
Authorized Official - Middle Name:I
Authorized Official - Last Name:PITTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-632-7641
Mailing Address - Street 1:1914 LELARAY ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-2800
Mailing Address - Country:US
Mailing Address - Phone:712-632-7641
Mailing Address - Fax:719-632-2925
Practice Address - Street 1:1000 RUSH DR
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-9627
Practice Address - Country:US
Practice Address - Phone:719-530-2487
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04850046Medicaid