Provider Demographics
NPI:1316162464
Name:ADULT MEDICINE SPECIALISTS PC
Entity type:Organization
Organization Name:ADULT MEDICINE SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:K
Authorized Official - Last Name:PRUTCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-546-3511
Mailing Address - Street 1:314 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003
Mailing Address - Country:US
Mailing Address - Phone:719-546-3511
Mailing Address - Fax:719-583-1292
Practice Address - Street 1:314 W 16TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2728
Practice Address - Country:US
Practice Address - Phone:719-546-3511
Practice Address - Fax:719-583-1292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23565207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04004313Medicaid
CA1208Medicare ID - Type Unspecified