MEDICARE: COLORADO INSTITUTE FOR PAIN MANAGEMENT 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	208100000X	Physical Medicine & Rehabilitation Physician	30232	CO
2	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	30232	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	103200300	OTHER	CO	DEPARTMENT OF LABOR PROVIDER ID
2	4489508	OTHER	CO	CIGNA PROVIDER ID
3	4489508	OTHER	CO	AETNA PROVIDER ID

General Provider Information

NPI Number	:	1447643127
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLORADO INSTITUTE FOR PAIN MANAGEMENT LLC

Provider Business Mailing Address
First Line	:	3910 S CAREFREE CIR STE C
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80917-3053
Country	:	US
Telephone Number	:	719-599-5753
Fax Number	:	719-599-5817

Provider Business Practice Location Address
First Line	:	3910 S CAREFREE CIR STE C
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80917-3053
Country	:	US
Telephone Number	:	719-599-5753
Fax Number	:	719-599-5817

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. JOHN MASON TYLER JR.
Credential	:	M.D.
Telephone Number	:	719-599-5753

Provider Enumeration Date	:	03/05/2015
Last Update Date	:	12/19/2016

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Directions to “COLORADO INSTITUTE FOR PAIN MANAGEMENT LLC ” Practice Location

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