Provider Demographics
NPI:1023237914
Name:WILLIAM R. BOULDEN MD PC
Entity type:Organization
Organization Name:WILLIAM R. BOULDEN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:BOULDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:515-440-2676
Mailing Address - Street 1:12499 UNIVERSITY AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50325-8281
Mailing Address - Country:US
Mailing Address - Phone:515-440-2676
Mailing Address - Fax:515-440-2677
Practice Address - Street 1:12499 UNIVERSITY AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50325-8281
Practice Address - Country:US
Practice Address - Phone:515-440-2676
Practice Address - Fax:515-440-2677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19337207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA50215OtherWELLMARK BLUE SHIELD
IACR0838OtherRAILROAD MEDICARE
IA4947140001Medicare NSC
IACR0838OtherRAILROAD MEDICARE