Provider Demographics
NPI:1477039907
Name:BOULDER BIOLOGICS, LLC
Entity Type:Organization
Organization Name:BOULDER BIOLOGICS, LLC
Other - Org Name:BOULDER BIOLOGICS, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:WELLS
Authorized Official - Last Name:GLOWNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:720-550-6175
Mailing Address - Street 1:4745 ARAPAHOE AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-1292
Mailing Address - Country:US
Mailing Address - Phone:720-550-6175
Mailing Address - Fax:
Practice Address - Street 1:4745 ARAPAHOE AVE STE 300
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1292
Practice Address - Country:US
Practice Address - Phone:720-550-6175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-18
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO47816207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1922264175OtherINDIVIDUAL NPI NUMBER FOR JASON GLOWNEY