Healthcare Provider Details

I. General information

NPI: 1861093841
Provider Name (Legal Business Name): PUEBLO RADIOLOGICAL GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2020
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 N ACADEMY BLVD STE 155
COLORADO SPRINGS CO
80909-1569
US

IV. Provider business mailing address

PO BOX 7693
LOVELAND CO
80537-0693
US

V. Phone/Fax

Practice location:
  • Phone: 719-380-7210
  • Fax: 719-542-7019
Mailing address:
  • Phone: 970-663-2742
  • Fax: 970-342-2093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROBIN L BOYER
Title or Position: AUTH REP/DIRECTOR OF OPERATIONS
Credential:
Phone: 970-663-2742