Provider Demographics
NPI:1184731721
Name:COLORADO SPRINGS ALLERGY & ASTHMA CLINIC, PC
Entity type:Organization
Organization Name:COLORADO SPRINGS ALLERGY & ASTHMA CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-592-1582
Mailing Address - Street 1:3425 AUSTIN BLUFFS PKWY
Mailing Address - Street 2:SUITE 205
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-5701
Mailing Address - Country:US
Mailing Address - Phone:719-592-1365
Mailing Address - Fax:719-592-1370
Practice Address - Street 1:3425 AUSTIN BLUFFS PKWY
Practice Address - Street 2:SUITE 205
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-5701
Practice Address - Country:US
Practice Address - Phone:719-592-1365
Practice Address - Fax:719-592-1370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04010765Medicaid
CO04010765Medicaid