Provider Demographics
NPI:1417957275
Name:COLORADO SPRINGS ORTHOPAEDIC GROUP
Entity Type:Organization
Organization Name:COLORADO SPRINGS ORTHOPAEDIC GROUP
Other - Org Name:AUDUBON ORTHOTIC AND PROSTHETIC SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MS
Authorized Official - First Name:AUTUMN
Authorized Official - Middle Name:
Authorized Official - Last Name:WULF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-632-7669
Mailing Address - Street 1:4110 BRIARGATE PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7837
Mailing Address - Country:US
Mailing Address - Phone:719-632-7669
Mailing Address - Fax:719-867-7322
Practice Address - Street 1:1259 LAKE PLAZA DR STE 100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3542
Practice Address - Country:US
Practice Address - Phone:719-867-7335
Practice Address - Fax:719-867-7378
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLORADO SPRINGS ORTHOPAEDIC GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-07-22
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO332B00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO34434381Medicaid
CO34434381Medicaid
1020310002Medicare NSC
CS2008Medicare PIN
COCS2408Medicare PIN