1568444271 NPI number — PUEBLO RADIOLOGICAL GROUP, P.C.

Table of content: (NPI 1568444271)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568444271 NPI number — PUEBLO RADIOLOGICAL GROUP, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PUEBLO RADIOLOGICAL GROUP, 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:
1568444271
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7693
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOVELAND
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80537-0693
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-663-2742
Provider Business Mailing Address Fax Number:
970-342-2093

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1008 MINNEQUA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81004-3733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-584-7410
Provider Business Practice Location Address Fax Number:
719-542-7019
Provider Enumeration Date:
11/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BOYER
Authorized Official First Name:
ROBIN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS-BILLING
Authorized Official Telephone Number:
970-663-2742

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 04870085 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 017160400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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