MEDICARE: ACADEMIC NEUROLOGY & HEADACHE CLINIC PC

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	174400000X	Specialist	24546	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083833834
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACADEMIC NEUROLOGY & HEADACHE CLINIC PC

Provider Business Mailing Address
First Line	:	2301 E PIKES PEAK AVE
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-8006
Country	:	US
Telephone Number	:	719-630-1510
Fax Number	:	719-632-7343

Provider Business Practice Location Address
First Line	:	2301 E PIKES PEAK AVE
Second Line	:	SUITE 202
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-8006
Country	:	US
Telephone Number	:	719-630-1510
Fax Number	:	719-632-7343

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BRUCE H PETERS
Credential	:	M.D.
Telephone Number	:	719-630-1510

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	12/14/2009

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