Provider Demographics
NPI:1093752834
Name:BOULDER NEUROSURGICAL ASSOCIATES
Entity Type:Organization
Organization Name:BOULDER NEUROSURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLAVICENCIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-938-5700
Mailing Address - Street 1:4743 ARAPAHOE AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-1128
Mailing Address - Country:US
Mailing Address - Phone:303-938-5700
Mailing Address - Fax:303-998-0007
Practice Address - Street 1:4743 ARAPAHOE AVE STE 202
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1128
Practice Address - Country:US
Practice Address - Phone:303-938-5700
Practice Address - Fax:303-998-0007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COGROUP207T00000X
207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO441038Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
COC441038Medicare PIN