MEDICARE: DR. RAYMOND L. WAHL M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	14055	CO

General Provider Information

NPI Number	:	1003951351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RAYMOND L. WAHL M.D.

Provider Business Mailing Address
First Line	:	45 POLO DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-3175
Country	:	US
Telephone Number	:	719-633-1578
Fax Number	:

Provider Business Practice Location Address
First Line	:	2502 E PIKES PEAK AVE
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-6033
Country	:	US
Telephone Number	:	719-630-6440
Fax Number	:	719-228-6603

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	07/08/2007

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