Provider Demographics
NPI:1306274675
Name:BRIAN A SURAGE PT MOMT CSCS PC
Entity type:Organization
Organization Name:BRIAN A SURAGE PT MOMT CSCS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:SURAGE
Authorized Official - Suffix:
Authorized Official - Credentials:PT MOMT CSCS
Authorized Official - Phone:719-268-8939
Mailing Address - Street 1:4209 CENTENNIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-3770
Mailing Address - Country:US
Mailing Address - Phone:719-268-8939
Mailing Address - Fax:719-268-0944
Practice Address - Street 1:4209 CENTENNIAL BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-3770
Practice Address - Country:US
Practice Address - Phone:719-268-8939
Practice Address - Fax:719-268-0944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-24
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO28022251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPENDINGOtherGROUP MEDICARE PENDING