Provider Demographics
NPI:1649838590
Name:BOULDER CARE PROVIDER GROUP PA
Entity type:Organization
Organization Name:BOULDER CARE PROVIDER GROUP PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OPERATIONS, AUTHORIZED AGENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:PIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIVDASANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-288-4715
Mailing Address - Street 1:111 SW NAITO PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-3512
Mailing Address - Country:US
Mailing Address - Phone:503-208-5061
Mailing Address - Fax:833-260-2594
Practice Address - Street 1:111 SW NAITO PKWY STE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-3512
Practice Address - Country:US
Practice Address - Phone:888-316-0451
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-04
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty