MEDICARE: PHYSICIAN SERVICES OF COLORADO LLC

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	207Q00000X	Family Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PHC059	OTHER		MEDICARE PTAN

General Provider Information

NPI Number	:	1316325251
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICIAN SERVICES OF COLORADO LLC

Provider Business Mailing Address
First Line	:	800 N MAGNOLIA AVE STE 700
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32803-3264
Country	:	US
Telephone Number	:	407-480-5986
Fax Number	:

Provider Business Practice Location Address
First Line	:	6005 DELMONICO DR
Second Line	:	SUITE 150
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80919-2237
Country	:	US
Telephone Number	:	407-480-5986
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	CASEY DELOACH
Credential	:
Telephone Number	:	888-829-8550

Provider Enumeration Date	:	05/12/2015
Last Update Date	:	05/21/2026

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