1114999018 NPI number — DERMATOLOGY AND ENDOCRINOLOGY LLC

Table of content: DR. ISAAC J.T. OSBORNE M.D. (NPI 1700809555)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114999018 NPI number — DERMATOLOGY AND ENDOCRINOLOGY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMATOLOGY AND ENDOCRINOLOGY LLC
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:
1114999018
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1925 E ORMAN AVE
Provider Second Line Business Mailing Address:
STE 115
Provider Business Mailing Address City Name:
PUEBLO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81004-3537
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-564-4500
Provider Business Mailing Address Fax Number:
719-564-0304

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1925 E ORMAN AVE
Provider Second Line Business Practice Location Address:
STE 115
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81004-3500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-564-4500
Provider Business Practice Location Address Fax Number:
719-564-0304
Provider Enumeration Date:
02/03/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DERNOVSEK
Authorized Official First Name:
KIM
Authorized Official Middle Name:
K
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
719-564-4500

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X , with the licence number:  26084 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207N00000X , with the licence number: 26083 , 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: 96378352 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1114999018 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".