1295929503 NPI number — BOULDER FAMILY MEDICINE, PC

Table of content: (NPI 1295929503)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295929503 NPI number — BOULDER FAMILY MEDICINE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOULDER FAMILY MEDICINE, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295929503
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 ALPINE AVE
Provider Second Line Business Mailing Address:
STE 260
Provider Business Mailing Address City Name:
BOULDER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80304-3406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-996-6923
Provider Business Mailing Address Fax Number:
303-996-6926

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 ALPINE AVE
Provider Second Line Business Practice Location Address:
STE 260
Provider Business Practice Location Address City Name:
BOULDER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80304-3406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-996-6923
Provider Business Practice Location Address Fax Number:
303-996-6926
Provider Enumeration Date:
08/29/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TAWA
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER/OWNER
Authorized Official Telephone Number:
303-996-6923

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  28790 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: C802261 . This is a "MEDICARE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 01287903 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".