Provider Demographics
NPI:1790978393
Name:KALLGREN DERMATOLOGY CLINIC, P.C.
Entity Type:Organization
Organization Name:KALLGREN DERMATOLOGY CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGUIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-444-8100
Mailing Address - Street 1:3434 47TH ST
Mailing Address - Street 2:#200
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1880
Mailing Address - Country:US
Mailing Address - Phone:303-444-8100
Mailing Address - Fax:303-444-8113
Practice Address - Street 1:3434 47TH ST
Practice Address - Street 2:#200
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1880
Practice Address - Country:US
Practice Address - Phone:303-444-8100
Practice Address - Fax:303-444-8113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO33197207N00000X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO804658Medicare PIN
COF76653Medicare UPIN