Provider Demographics
NPI:1881630309
Name:PRINTERS PARK OBGYN, A PROFESSIONAL, LLC
Entity Type:Organization
Organization Name:PRINTERS PARK OBGYN, A PROFESSIONAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED MEDICAL MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:OGDEN
Authorized Official - Suffix:
Authorized Official - Credentials:CMM
Authorized Official - Phone:719-634-1532
Mailing Address - Street 1:175 S UNION BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-3147
Mailing Address - Country:US
Mailing Address - Phone:719-634-1532
Mailing Address - Fax:719-634-1715
Practice Address - Street 1:175 S UNION BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3147
Practice Address - Country:US
Practice Address - Phone:719-634-1532
Practice Address - Fax:719-634-1715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPRU3708OtherGROUP ANTHEM BCBS NUMBER
CO04018677Medicaid
COPRU3708OtherGROUP ANTHEM BCBS NUMBER