Provider Demographics
NPI:1023234861
Name:PEDIATRIC ASSOCIATES OF SOUTHERN COLORADO, LLC
Entity type:Organization
Organization Name:PEDIATRIC ASSOCIATES OF SOUTHERN COLORADO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PUDUPAKKAM
Authorized Official - Middle Name:K
Authorized Official - Last Name:VEDANTHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-238-0471
Mailing Address - Street 1:2020 WADSWORTH BLVD
Mailing Address - Street 2:SUITE 13A
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80214-5728
Mailing Address - Country:US
Mailing Address - Phone:303-238-0471
Mailing Address - Fax:303-238-6711
Practice Address - Street 1:1312 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2718
Practice Address - Country:US
Practice Address - Phone:719-544-2090
Practice Address - Fax:719-544-2094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO39188361Medicaid