Provider Demographics
NPI:1548469679
Name:INTERNAL MEDICINE AND ALLERGY PC
Entity type:Organization
Organization Name:INTERNAL MEDICINE AND ALLERGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:DUCHARME
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-630-0307
Mailing Address - Street 1:310 E DEL NORTE ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-7512
Mailing Address - Country:US
Mailing Address - Phone:719-630-0307
Mailing Address - Fax:719-630-1507
Practice Address - Street 1:310 E DEL NORTE ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-7512
Practice Address - Country:US
Practice Address - Phone:719-630-0307
Practice Address - Fax:719-630-1507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17465207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04011359Medicaid
COC26611Medicare PIN
CO04011359Medicaid