=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134184914
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PUEBLO RADIATION ONCOLOGY, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2006
-----------------------------------------------------
Last Update Date | 07/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1008 MINNEQUA AVE
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81004-3733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-560-5482
-----------------------------------------------------
Fax | 719-560-7217
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1008 MINNEQUA AVE
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81004-3733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-560-5482
-----------------------------------------------------
Fax | 719-560-7217
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | JOHN D STAGEBERG
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 719-560-5482
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------