1477794428 NPI number — PAMELA W. CASSON, MD, PC

Table of content: (NPI 1477794428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477794428 NPI number — PAMELA W. CASSON, MD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAMELA W. CASSON, MD, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SUNRISE PEDIATRICS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477794428
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5605 COACHWOOD TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80919-4454
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-598-0631
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1465 KELLY JOHNSON BLVD
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80920-3955
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-265-1050
Provider Business Practice Location Address Fax Number:
719-265-2503
Provider Enumeration Date:
03/19/2009

Additional Information

Authorized Official

Authorized Official Last Name:
CASSON
Authorized Official First Name:
PAMELA
Authorized Official Middle Name:
WALLACE
Authorized Official Title or Position:
PEDIATRICIAN
Authorized Official Telephone Number:
719-598-0631

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 85487210 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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