Provider Demographics
NPI:1801208236
Name:COLORADO SPINE INSTITUTE PROFESSIONAL LLC
Entity Type:Organization
Organization Name:COLORADO SPINE INSTITUTE PROFESSIONAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:DONNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-342-2220
Mailing Address - Street 1:4795 LARIMER PKWY
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:CO
Mailing Address - Zip Code:80534-9021
Mailing Address - Country:US
Mailing Address - Phone:970-342-2220
Mailing Address - Fax:970-342-2221
Practice Address - Street 1:4795 LARIMER PKWY
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:CO
Practice Address - Zip Code:80534-9021
Practice Address - Country:US
Practice Address - Phone:970-342-2220
Practice Address - Fax:970-342-2221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-20
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30264207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COB7728Medicare PIN
COB41729Medicare UPIN