Provider Demographics
NPI:1376879254
Name:COLORADO SPRINGS NEPHROLOGY
Entity Type:Organization
Organization Name:COLORADO SPRINGS NEPHROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVENZANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-237-6302
Mailing Address - Street 1:45640 SCHOENHERR RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-6033
Mailing Address - Country:US
Mailing Address - Phone:866-691-6243
Mailing Address - Fax:
Practice Address - Street 1:1725 E BOULDER ST
Practice Address - Street 2:SUITE 105
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5768
Practice Address - Country:US
Practice Address - Phone:866-691-6243
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-27
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty