Provider Demographics
NPI:1477608891
Name:KEITH O BODRERO DO PC DBA POWERS MEDICAL
Entity Type:Organization
Organization Name:KEITH O BODRERO DO PC DBA POWERS MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-550-9100
Mailing Address - Street 1:6080 N CAREFREE CIR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80922-2402
Mailing Address - Country:US
Mailing Address - Phone:719-550-9100
Mailing Address - Fax:719-380-0384
Practice Address - Street 1:6080 N CAREFREE CIR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80922-2402
Practice Address - Country:US
Practice Address - Phone:719-550-9100
Practice Address - Fax:719-380-0384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO32687207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01326875Medicaid
CO01326875Medicaid