MEDICARE: COLORADO SPRINGS RADIOLOGISTS 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	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1376153965
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLORADO SPRINGS RADIOLOGISTS PC

Provider Business Mailing Address
First Line	:	PO BOX 2989
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80901-2989
Country	:	US
Telephone Number	:	719-593-1799
Fax Number	:	719-265-3794

Provider Business Practice Location Address
First Line	:	5607 BARNES RD # 140
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80917-1347
Country	:	US
Telephone Number	:	719-593-1799
Fax Number	:	719-265-3794

Authorized Official
Title or Position	:	RADIOLOGIST
Name	:	DEREK SCOTT BERGESON
Credential	:	MD
Telephone Number	:	719-593-1799

Provider Enumeration Date	:	08/07/2020
Last Update Date	:	08/07/2020

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