Basic Information
| Provider Information | |||||||||
| NPI: | 1144844424 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OBSTETRIX MEDICAL GROUP OF COLORADO, P.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ROCKY MOUNTAIN PEDIATRIC CARDIOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4722 N 24TH ST STE 150 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850164860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8777374546 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6965 TUTT BLVD STE 310 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809233596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038609933 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2020 | ||||||||
| LastUpdateDate: | 09/13/2021 | ||||||||
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| AuthorizedOfficialLastName: | RANDOLPH | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3037885000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 09/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 79185002 | 05 | CO | MEDICAID |