1205006145 NPI number — MICHAEL G PHARRIS OD PC

Table of content: KENNETH L GOETZ MD (NPI 1588775704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205006145 NPI number — MICHAEL G PHARRIS OD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL G PHARRIS OD 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:
Provider Other Organization Name Type Code:
6
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:
1205006145
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/09/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2221 E BIJOU ST.
Provider Second Line Business Mailing Address:
STE. 100
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-727-4746
Provider Business Mailing Address Fax Number:
410-727-6767

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1253 W PRATT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21223-2684
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-727-4746
Provider Business Practice Location Address Fax Number:
410-727-6767
Provider Enumeration Date:
03/06/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LEBLANC
Authorized Official First Name:
SAMANTHA
Authorized Official Middle Name:
B
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
719-323-2372

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 304036400 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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