Provider Demographics
NPI:1356448807
Name:REIMS, RANDOLPH G (MD)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:G
Last Name:REIMS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5450 WESTERN AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-2709
Mailing Address - Country:US
Mailing Address - Phone:303-415-4770
Mailing Address - Fax:303-415-4769
Practice Address - Street 1:1000 W SOUTH BOULDER RD
Practice Address - Street 2:SUITE 214
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-2752
Practice Address - Country:US
Practice Address - Phone:303-604-4660
Practice Address - Fax:303-604-4662
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30677207R00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01306778Medicaid
CO01306778Medicaid
COCOA101847Medicare PIN