Provider Demographics
NPI:1932180304
Name:COLORADO SPRINGS INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:COLORADO SPRINGS INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:VICKY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BONATO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-633-5515
Mailing Address - Street 1:175 S UNION BLVD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-3113
Mailing Address - Country:US
Mailing Address - Phone:719-633-5515
Mailing Address - Fax:719-471-2258
Practice Address - Street 1:175 S UNION BLVD
Practice Address - Street 2:SUITE 350
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3113
Practice Address - Country:US
Practice Address - Phone:719-633-5515
Practice Address - Fax:719-471-2258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04015269Medicaid
CO04015269Medicaid