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General NPI Number Information
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NPI Number | 1104001379
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Entity Type | Organization
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Legal Business Name | UROLOGY OF SOUTHERN COLORADO PLLC
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Dates
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Enumeration Date | 01/07/2008
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Last Update Date | 10/15/2009
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Provider Practice Location Address
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Address Line | 3676 PARKER BLVD SUITE 310
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City | PUEBLO
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State | CO
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Zip | 81008-2212
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Country | US
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Telephone | 719-545-1500
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Fax |
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Provider Business Mailing Address
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Address Line | 3676 PARKER BLVD SUITE 310
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City | PUEBLO
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State | CO
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Zip | 81008-2212
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Country | US
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Telephone | 719-545-1500
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DANA JOAN WEAVER-OSTERHOLTZ
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Credential | M.D.
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Telephone | 719-676-3728
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 40134
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License Number State | CO
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