Provider Demographics
NPI:1720285695
Name:KENNETH D DANYLCHUK, MD, PC
Entity Type:Organization
Organization Name:KENNETH D DANYLCHUK, MD, PC
Other - Org Name:MAPLE LEAF ORTHOPEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANA
Authorized Official - Middle Name:D
Authorized Official - Last Name:STOLLSTEIMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-296-9000
Mailing Address - Street 1:3530 SPAULDING AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2209
Mailing Address - Country:US
Mailing Address - Phone:719-296-9000
Mailing Address - Fax:719-296-9001
Practice Address - Street 1:3530 SPAULDING AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2209
Practice Address - Country:US
Practice Address - Phone:719-296-9000
Practice Address - Fax:719-296-9001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO29760174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01297605Medicaid
CO01297605Medicaid
COC382608Medicare PIN
CO5337280001Medicare NSC