MEDICARE: COLORADO SPRINGS DERMATOLOGY CLINIC, 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	207N00000X	Dermatology Physician
2	207ND0101X	MOHS-Micrographic Surgery Physician

General Provider Information

NPI Number	:	1720685894
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLORADO SPRINGS DERMATOLOGY CLINIC, P.C.

Provider Business Mailing Address
First Line	:	170 S PARKSIDE DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80910-3129
Country	:	US
Telephone Number	:	719-471-1763
Fax Number	:	719-471-2498

Provider Business Practice Location Address
First Line	:	1332 BAUER LN
Second Line	:
City	:	CANON CITY
State	:	CO
Zip	:	81212-4669
Country	:	US
Telephone Number	:	719-275-7485
Fax Number	:	719-275-5331

Authorized Official
Title or Position	:	BILLING DEPARTMENT MANAGER
Name	:	HEATHER MILENSKI
Credential	:
Telephone Number	:	719-471-1763

Provider Enumeration Date	:	10/02/2020
Last Update Date	:	09/05/2024

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