MEDICARE: PRINTERS PARK OBGYN, A PROFESSIONAL, 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	207V00000X	Obstetrics & Gynecology Physician		CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PRU3708	OTHER	CO	GROUP ANTHEM BCBS NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881630309
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRINTERS PARK OBGYN, A PROFESSIONAL, LLC

Provider Business Mailing Address
First Line	:	175 S UNION BLVD
Second Line	:	SUITE 220
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80910-3147
Country	:	US
Telephone Number	:	719-634-1532
Fax Number	:	719-634-1715

Provider Business Practice Location Address
First Line	:	175 S UNION BLVD
Second Line	:	SUITE 220
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80910-3147
Country	:	US
Telephone Number	:	719-634-1532
Fax Number	:	719-634-1715

Authorized Official
Title or Position	:	CERTIFIED MEDICAL MANAGER
Name	:	MS. SUSAN M OGDEN
Credential	:	CMM
Telephone Number	:	719-634-1532

Provider Enumeration Date	:	06/22/2006
Last Update Date	:	09/21/2010

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