Provider Demographics
NPI:1376686691
Name:CANON CITY OBGYN PC
Entity Type:Organization
Organization Name:CANON CITY OBGYN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PELHAM
Authorized Official - Middle Name:PORTER
Authorized Official - Last Name:STAPLES
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:719-275-5261
Mailing Address - Street 1:1335 PHAY AVE
Mailing Address - Street 2:STE C
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-2334
Mailing Address - Country:US
Mailing Address - Phone:719-275-5261
Mailing Address - Fax:719-275-1687
Practice Address - Street 1:1335 PHAY AVE
Practice Address - Street 2:STE C
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-2334
Practice Address - Country:US
Practice Address - Phone:719-275-5261
Practice Address - Fax:719-275-1687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30880207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1679521322OtherDR STAPLES NPI
CO01308808Medicaid
COF66095Medicare UPIN
CO01308808Medicaid