Basic Information
| Provider Information | |||||||||
| NPI: | 1043276074 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAGNUSON | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | NILS | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 SOUTH UNION BLVD | ||||||||
| Address2: | PEAK VISTA COMMUNITY HEALTH CENTERS FAMILY CARE CLINIC | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809103195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193446440 | ||||||||
| FaxNumber: | 7193447838 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 SOUTH UNION BLVD | ||||||||
| Address2: | PEAK VISTA COMMUNITY HEALTH CENTERS | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809103195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196325700 | ||||||||
| FaxNumber: | 7193443878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 12/23/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 41927 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 86485725 | 05 | CO | MEDICAID |