MEDICARE: PIKES PEAK CARDIOLOGY A PROFESSIONAL LLP

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

General Provider Information

NPI Number	:	1558363705
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PIKES PEAK CARDIOLOGY A PROFESSIONAL LLP

Provider Business Mailing Address
First Line	:	PO BOX 9809
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80932-0809
Country	:	US
Telephone Number	:	719-635-7172
Fax Number	:

Provider Business Practice Location Address
First Line	:	1400 E BOULDER ST
Second Line	:	SUITE 700
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-5533
Country	:	US
Telephone Number	:	719-635-7172
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. WILLIAM MANTIA III
Credential	:
Telephone Number	:	719-635-7172

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	12/04/2007

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