Provider Demographics
NPI:1144341959
Name:AGEWELL MEDICAL ASSOCIATES, PC
Entity type:Organization
Organization Name:AGEWELL MEDICAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:T
Authorized Official - Last Name:KULP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-475-5065
Mailing Address - Street 1:2350 INTERNATIONAL CIR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-3139
Mailing Address - Country:US
Mailing Address - Phone:719-475-5065
Mailing Address - Fax:719-475-5797
Practice Address - Street 1:2350 INTERNATIONAL CIR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3139
Practice Address - Country:US
Practice Address - Phone:719-475-5065
Practice Address - Fax:719-475-5797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC808193Medicare PIN
CODF7570Medicare PIN