Provider Demographics
NPI:1134164593
Name:PUEBLO CARDIOLOGY ASSOC PC
Entity type:Organization
Organization Name:PUEBLO CARDIOLOGY ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:STJERNHOLM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-564-1544
Mailing Address - Street 1:3670 PARKER BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2207
Mailing Address - Country:US
Mailing Address - Phone:719-564-1544
Mailing Address - Fax:719-924-1593
Practice Address - Street 1:3670 PARKER BLVD STE 101
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2207
Practice Address - Country:US
Practice Address - Phone:719-564-1544
Practice Address - Fax:719-924-1593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04006532Medicaid
COC11508Medicare PIN