MEDICARE: COLORADO CENTER FOR OTOLARYNGOLOGY, PROFESSIONAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207YX0905X	Otolaryngology/Facial Plastic Surgery Physician	BC2020422	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164421582
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLORADO CENTER FOR OTOLARYNGOLOGY, PROFESSIONAL LLC

Provider Business Mailing Address
First Line	:	3920 N UNION BLVD
Second Line	:	SUITE 310
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80907-4900
Country	:	US
Telephone Number	:	719-574-6653
Fax Number	:	719-574-2778

Provider Business Practice Location Address
First Line	:	3920 N UNION BLVD
Second Line	:	SUITE 310
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80907-4900
Country	:	US
Telephone Number	:	719-574-6653
Fax Number	:	719-574-2778

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. DANIEL K SMITH
Credential	:	M.D.
Telephone Number	:	719-574-6653

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	01/05/2011

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