Provider Demographics
NPI:1457498131
Name:PEDIATRIC ASSOCIATES OF CANON CITY, PROF. LLC
Entity Type:Organization
Organization Name:PEDIATRIC ASSOCIATES OF CANON CITY, PROF. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:DEANE
Authorized Official - Last Name:NOLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-269-1727
Mailing Address - Street 1:1335 PHAY AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-2334
Mailing Address - Country:US
Mailing Address - Phone:719-269-1727
Mailing Address - Fax:719-269-1730
Practice Address - Street 1:1335 PHAY AVE
Practice Address - Street 2:SUITE A
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-2334
Practice Address - Country:US
Practice Address - Phone:719-269-1727
Practice Address - Fax:719-269-1730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO231172080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05638655Medicaid
CO01271139Medicaid
CO05638655Medicaid