Provider Demographics
NPI:1376789552
Name:PHYSIOM, LLC
Entity Type:Organization
Organization Name:PHYSIOM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AGENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANDEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHRODER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-922-4636
Mailing Address - Street 1:PHYSIOM LLC DEPT 2089
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-0001
Mailing Address - Country:US
Mailing Address - Phone:303-922-4636
Mailing Address - Fax:303-922-4640
Practice Address - Street 1:1300 OAKRIDGE DR
Practice Address - Street 2:130
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-5564
Practice Address - Country:US
Practice Address - Phone:970-377-9555
Practice Address - Fax:970-377-9559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-18
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31928174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty