Healthcare Provider Details

I. General information

NPI: 1962498717
Provider Name (Legal Business Name): COLORADO SPRINGS PLASTIC SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2727 N TEJON ST
COLORADO SPRINGS CO
80907-6231
US

IV. Provider business mailing address

2727 N TEJON ST
COLORADO SPRINGS CO
80907-6231
US

V. Phone/Fax

Practice location:
  • Phone: 719-632-1818
  • Fax: 719-632-4615
Mailing address:
  • Phone: 719-632-1818
  • Fax: 719-632-4615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number18974
License Number StateCO

VIII. Authorized Official

Name: MRS. GEORGETTE MATHEWS
Title or Position: BILLING REPRESENTATIVE
Credential:
Phone: 719-632-1818