Provider Demographics
NPI:1295929503
Name:BOULDER FAMILY MEDICINE, PC
Entity type:Organization
Organization Name:BOULDER FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:TAWA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-996-6923
Mailing Address - Street 1:1000 ALPINE AVE
Mailing Address - Street 2:STE 260
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-3406
Mailing Address - Country:US
Mailing Address - Phone:303-996-6923
Mailing Address - Fax:303-996-6926
Practice Address - Street 1:1000 ALPINE AVE
Practice Address - Street 2:STE 260
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3406
Practice Address - Country:US
Practice Address - Phone:303-996-6923
Practice Address - Fax:303-996-6926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO28790207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC802261OtherMEDICARE
CO01287903Medicaid