Provider Demographics
NPI:1598936163
Name:COLORADO SURGICAL CLINIC, PC
Entity Type:Organization
Organization Name:COLORADO SURGICAL CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:W
Authorized Official - Last Name:RENEHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD,DDS
Authorized Official - Phone:719-540-6350
Mailing Address - Street 1:640 SOUTHPOINTE CT
Mailing Address - Street 2:150
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3856
Mailing Address - Country:US
Mailing Address - Phone:719-540-6350
Mailing Address - Fax:719-527-9487
Practice Address - Street 1:640 SOUTHPOINTE CT
Practice Address - Street 2:150
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3856
Practice Address - Country:US
Practice Address - Phone:719-540-6350
Practice Address - Fax:719-527-9487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-21
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO85081223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO49086804Medicaid