1730147000 NPI number — HEATHER BOURKOVSKI DO

Table of content: HEATHER BOURKOVSKI DO (NPI 1730147000)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730147000 NPI number — HEATHER BOURKOVSKI DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOURKOVSKI
Provider First Name:
HEATHER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

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:
1730147000
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2160 PEREGRINE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND JUNCTION
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81507-8794
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-628-5840
Provider Business Mailing Address Fax Number:
970-255-9641

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2525 N 8TH ST STE 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND JUNCTION
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-245-1168
Provider Business Practice Location Address Fax Number:
970-242-4299
Provider Enumeration Date:
05/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  O-0371 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 50461 , 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: 000010167598 . This is a "RBS LAMERE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: S6242 . This is a "BCS LAMERE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 312947 . This is a "ALTIUS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010151852 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 265447 . This is a "ALTIUS OLD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: S5882 . This is a "BLUE CROSS OLD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: S6112 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: COAAA3029 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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