Provider Demographics
NPI:1275541666
Name:CENTENNIAL SURGICAL ASSOCIATES,PLLC
Entity Type:Organization
Organization Name:CENTENNIAL SURGICAL ASSOCIATES,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-566-3535
Mailing Address - Street 1:1600 N GRAND AVE
Mailing Address - Street 2:STE 510
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2700
Mailing Address - Country:US
Mailing Address - Phone:719-566-3535
Mailing Address - Fax:719-566-3565
Practice Address - Street 1:1600 N GRAND AVE
Practice Address - Street 2:STE 510
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2700
Practice Address - Country:US
Practice Address - Phone:719-566-3535
Practice Address - Fax:719-566-3565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO24179078Medicaid
CO24179078Medicaid