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General NPI Number Information
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NPI Number | 1841339447
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Entity Type | Organization
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Legal Business Name | SURGICAL CONSULTANTS OF PUEBLO, PC
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Dates
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Enumeration Date | 02/06/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1026 W ABRIENDO AVE
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City | PUEBLO
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State | CO
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Zip | 81004-1128
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Country | US
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Telephone | 719-561-1161
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Fax |
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Provider Business Mailing Address
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Address Line | 124 CARRILLON LN
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City | PUEBLO
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State | CO
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Zip | 81005
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Country | US
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Telephone | 719-561-1161
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. PAUL RAYMOND RADWAY
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Credential | MD
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Telephone | 719-561-1161
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 20508
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License Number State | CO
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