Provider Demographics
NPI:1447308465
Name:ROARING FORK SURGICAL ASSOCIATES PROF LLC
Entity type:Organization
Organization Name:ROARING FORK SURGICAL ASSOCIATES PROF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-945-6533
Mailing Address - Street 1:1906 BLAKE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601-4227
Mailing Address - Country:US
Mailing Address - Phone:970-945-6533
Mailing Address - Fax:970-945-3945
Practice Address - Street 1:1906 BLAKE AVE
Practice Address - Street 2:
Practice Address - City:GLENWOOD SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81601-4227
Practice Address - Country:US
Practice Address - Phone:970-945-6533
Practice Address - Fax:970-945-3945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208600000X
CO80.05611.1208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO607484OtherBCBS
COCG 5876OtherRR MEDICARE
CO04020459Medicaid
COCG 5876OtherRR MEDICARE
COCU9508Medicare PIN