Provider Demographics
NPI:1285795567
Name:PIKES PEAK CENTER FOR COLON & RECTAL SURGERY
Entity type:Organization
Organization Name:PIKES PEAK CENTER FOR COLON & RECTAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:RUDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-635-0454
Mailing Address - Street 1:559 EAST PIKES PEAK AVE
Mailing Address - Street 2:SUITE #300
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903
Mailing Address - Country:US
Mailing Address - Phone:719-635-0454
Mailing Address - Fax:719-473-3476
Practice Address - Street 1:559 EAST PIKES PEAK AVE
Practice Address - Street 2:SUITE #300
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903
Practice Address - Country:US
Practice Address - Phone:719-635-0454
Practice Address - Fax:719-473-3476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO42378208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO68302584Medicaid
CO68302584Medicaid