Provider Demographics
NPI:1447643127
Name:COLORADO INSTITUTE FOR PAIN MANAGEMENT LLC
Entity type:Organization
Organization Name:COLORADO INSTITUTE FOR PAIN MANAGEMENT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MASON
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:719-599-5753
Mailing Address - Street 1:3910 S CAREFREE CIR STE C
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-3053
Mailing Address - Country:US
Mailing Address - Phone:719-599-5753
Mailing Address - Fax:719-599-5817
Practice Address - Street 1:3910 S CAREFREE CIR STE C
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-3053
Practice Address - Country:US
Practice Address - Phone:719-599-5753
Practice Address - Fax:719-599-5817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-05
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30232208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO103200300OtherDEPARTMENT OF LABOR PROVIDER ID
CO4489508OtherCIGNA PROVIDER ID
CO4489508OtherAETNA PROVIDER ID
CO103200300OtherDEPARTMENT OF LABOR PROVIDER ID
CO4489508OtherCIGNA PROVIDER ID