MEDICARE: ENT CLINIC OF PUEBLO, P.C.

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	207Y00000X	Otolaryngology Physician

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	:	1710202593
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENT CLINIC OF PUEBLO, P.C.

Provider Business Mailing Address
First Line	:	1304 N GRAND AVE
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81003-2718
Country	:	US
Telephone Number	:	719-544-3752
Fax Number	:	719-542-1794

Provider Business Practice Location Address
First Line	:	1304 N GRAND AVE
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81003-2718
Country	:	US
Telephone Number	:	719-544-3752
Fax Number	:	719-542-1794

Authorized Official
Title or Position	:	OWNER/PROVIDER
Name	:	JULIE ANN NEWBURG
Credential	:	MD
Telephone Number	:	714-544-3752

Provider Enumeration Date	:	04/05/2010
Last Update Date	:	04/06/2010

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