Provider Demographics
NPI:1700839248
Name:PARKSIDE CT GROUP LLC
Entity Type:Organization
Organization Name:PARKSIDE CT GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D./MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:J.
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:CREPPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-477-1033
Mailing Address - Street 1:215 PARKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-3135
Mailing Address - Country:US
Mailing Address - Phone:719-477-1033
Mailing Address - Fax:719-477-1037
Practice Address - Street 1:215 PARKSIDE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3135
Practice Address - Country:US
Practice Address - Phone:719-477-1033
Practice Address - Fax:719-477-1037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO311242086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO31124OtherPHYSICIAN LICENSE