Provider Demographics
NPI:1902832603
Name:BOULDER VALLEY GASTROENTEROLOGY INC.
Entity Type:Organization
Organization Name:BOULDER VALLEY GASTROENTEROLOGY INC.
Other - Org Name:GASTROENTEROLOGY OF THE ROCKIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOARD MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAUS
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHNKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-604-5000
Mailing Address - Street 1:382 S ARTHUR AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-3094
Mailing Address - Country:US
Mailing Address - Phone:303-604-5000
Mailing Address - Fax:720-890-0364
Practice Address - Street 1:1000 W SOUTH BOULDER RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-2752
Practice Address - Country:US
Practice Address - Phone:303-604-5000
Practice Address - Fax:720-890-0364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCD5666OtherRAILROAD MEDICARE
COGAA1308OtherBCBS
CO04004180Medicaid
COCD5666OtherRAILROAD MEDICARE