Provider Demographics
NPI:1831572759
Name:THE PEAK PHYSICAL MEDICINE
Entity type:Organization
Organization Name:THE PEAK PHYSICAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:VAUGHN
Authorized Official - Last Name:SANDELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-591-5545
Mailing Address - Street 1:2955 PROFESSIONAL PL STE 201
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80904-8140
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2955 PROFESSIONAL PL STE 201
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-8140
Practice Address - Country:US
Practice Address - Phone:719-591-5545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-09
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO344082081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1679522254OtherNPI
CO01344084Medicaid
CO01344084Medicaid