Provider Demographics
NPI:1578601969
Name:CREEKSIDE PHYSICAL MEDICINE PLLC
Entity Type:Organization
Organization Name:CREEKSIDE PHYSICAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:303-494-2705
Mailing Address - Street 1:5387 MANHATTAN CIR
Mailing Address - Street 2:STE 201
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-4284
Mailing Address - Country:US
Mailing Address - Phone:303-494-2705
Mailing Address - Fax:303-494-2706
Practice Address - Street 1:5387 MANHATTAN CIR
Practice Address - Street 2:STE 201
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-4284
Practice Address - Country:US
Practice Address - Phone:303-494-2705
Practice Address - Fax:303-494-2706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO38635204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCO301623Medicare PIN
COC847341Medicare PIN
COC807492Medicare PIN
COH32430Medicare UPIN
COC301623Medicare PIN