Provider Demographics
NPI:1265780092
Name:DURTSCHI, BENJAMIN M (AA)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:M
Last Name:DURTSCHI
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:970-624-4034
Mailing Address - Fax:970-490-4347
Practice Address - Street 1:1400 E BOULDER ST STE 2508
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-365-6999
Practice Address - Fax:719-365-2837
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012029913367H00000X
COANT.0000129367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP01129105OtherRR MCR
MO431560263OtherTRICARE
MO1265780092Medicaid
MO1265780092Medicaid