Provider Demographics
NPI:1558579789
Name:PEDIATRIC GASTROENTEROLOGY OF COLORADO SPRINGS
Entity Type:Organization
Organization Name:PEDIATRIC GASTROENTEROLOGY OF COLORADO SPRINGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:YAZDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-590-1000
Mailing Address - Street 1:2925 PROFESSIONAL PL STE 103
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80904-8125
Mailing Address - Country:US
Mailing Address - Phone:719-590-1000
Mailing Address - Fax:719-590-1005
Practice Address - Street 1:2925 PROFESSIONAL PL STE 103
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-8125
Practice Address - Country:US
Practice Address - Phone:719-590-1000
Practice Address - Fax:719-590-1005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-20
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO35668174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO47329769Medicaid