1780866459 NPI number — INTERMOUNTAIN FOOT & ANKLE ASSOC P.C

Table of content: (NPI 1780866459)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780866459 NPI number — INTERMOUNTAIN FOOT & ANKLE ASSOC P.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERMOUNTAIN FOOT & ANKLE ASSOC P.C
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:
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:
1780866459
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9348 GRAND CORDERA
Provider Second Line Business Mailing Address:
PKWY 210
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80924-4062
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-594-9920
Provider Business Mailing Address Fax Number:
719-598-6212

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9348 GRAND CORDERA PKWY STE 210
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80924-7002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-594-9920
Provider Business Practice Location Address Fax Number:
719-598-6212
Provider Enumeration Date:
12/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BERG
Authorized Official First Name:
KERRY
Authorized Official Middle Name:
ELIZEBETH
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
719-594-9920

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  517 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CD1850 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 01005180 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 04532339 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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