Provider Demographics
NPI:1386699486
Name:SOUTHERN COLORADO RADIOLOGISTS, P.C.
Entity type:Organization
Organization Name:SOUTHERN COLORADO RADIOLOGISTS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:COOKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RT
Authorized Official - Phone:719-542-2167
Mailing Address - Street 1:PO BOX 11512
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-0512
Mailing Address - Country:US
Mailing Address - Phone:719-542-2167
Mailing Address - Fax:719-542-0320
Practice Address - Street 1:1619 N GREENWOOD ST STE 103
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2655
Practice Address - Country:US
Practice Address - Phone:719-542-2167
Practice Address - Fax:719-542-0320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04117081Medicaid
COC11708Medicare PIN