Basic Information
Provider Information | |||||||||
NPI: | 1013564517 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BOULDER COMMUNITY HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | COMMUNITY MEDICAL ASSOC OF BCH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9049 | ||||||||
Address2: |   | ||||||||
City: | BOULDER | ||||||||
State: | CO | ||||||||
PostalCode: | 803019049 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3034154250 | ||||||||
FaxNumber: | 3034409629 | ||||||||
Practice Location | |||||||||
Address1: | 5495 ARAPAHOE AVE STE 100 | ||||||||
Address2: |   | ||||||||
City: | BOULDER | ||||||||
State: | CO | ||||||||
PostalCode: | 803031224 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3034154250 | ||||||||
FaxNumber: | 3034409629 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/20/2019 | ||||||||
LastUpdateDate: | 06/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MUNSON | ||||||||
AuthorizedOfficialFirstName: | WILLIAM | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | VP/CFO | ||||||||
AuthorizedOfficialTelephone: | 3034157433 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | BOULDER COMMUNITY HEALTH | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/29/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.