Provider Demographics
NPI:1962668319
Name:BOULDER MEDICAL CENTER, PC
Entity Type:Organization
Organization Name:BOULDER MEDICAL CENTER, PC
Other - Org Name:BOULDER MEDICAL CENTER ASC
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-440-3123
Mailing Address - Street 1:2750 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-3573
Mailing Address - Country:US
Mailing Address - Phone:303-440-3000
Mailing Address - Fax:
Practice Address - Street 1:2750 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3573
Practice Address - Country:US
Practice Address - Phone:303-440-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-05
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO160365261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO160365OtherSTATE LICENSE AS AMBULATORY SURGICAL CENTER
COCA61015Medicare PIN