Provider Demographics
NPI:1336197631
Name:BOULDERCENTRE FOR ORTHOPEDICS PC
Entity Type:Organization
Organization Name:BOULDERCENTRE FOR ORTHOPEDICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:INGRID
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-607-6363
Mailing Address - Street 1:4740 PEARL PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-3078
Mailing Address - Country:US
Mailing Address - Phone:303-449-2730
Mailing Address - Fax:303-449-5821
Practice Address - Street 1:4740 PEARL PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3078
Practice Address - Country:US
Practice Address - Phone:303-449-2730
Practice Address - Fax:303-449-5821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC4508Medicare PIN