Healthcare Provider Details

I. General information

NPI: 1669578787
Provider Name (Legal Business Name): BRIAN ANTHONY SURAGE PT, MOMT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 11/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2228 N WAHSATCH AVE
COLORADO SPRINGS CO
80907-6940
US

IV. Provider business mailing address

337 WHISTLER CREEK CT
MONUMENT CO
80132-8987
US

V. Phone/Fax

Practice location:
  • Phone: 719-268-8939
  • Fax: 719-268-0944
Mailing address:
  • Phone: 719-268-8939
  • Fax: 719-268-0944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number2802
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: