Healthcare Provider Details

I. General information

NPI: 1740244342
Provider Name (Legal Business Name): TOMAS PEVNY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 03/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 E VALLEY RD SUITE 201
BASALT CO
81621-8304
US

IV. Provider business mailing address

1450 E VALLEY RD SUITE 201
BASALT CO
81621-8304
US

V. Phone/Fax

Practice location:
  • Phone: 970-927-8611
  • Fax: 970-927-8633
Mailing address:
  • Phone: 970-927-8611
  • Fax: 970-927-8633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number34527
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number34527
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: