Provider Demographics
NPI:1356317135
Name:COLORADO SPRINGS ORTHOPAEDIC GROUP
Entity Type:Organization
Organization Name:COLORADO SPRINGS ORTHOPAEDIC GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:WD
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:719-867-7371
Mailing Address - Street 1:4110 BRIARGATE PARKWAY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920
Mailing Address - Country:US
Mailing Address - Phone:719-632-7669
Mailing Address - Fax:719-632-0088
Practice Address - Street 1:1259 LAKE PLAZA DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906
Practice Address - Country:US
Practice Address - Phone:719-632-7669
Practice Address - Fax:719-632-0088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCS2008Medicare PIN