Basic Information
| Provider Information | |||||||||
| NPI: | 1043251432 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOULDER PLASTIC SURGERY PROF LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2525 4TH ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803043966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034432277 | ||||||||
| FaxNumber: | 3034437124 | ||||||||
| Practice Location | |||||||||
| Address1: | 2525 4TH ST | ||||||||
| Address2: | STE 202 | ||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803043966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004620975 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 02/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | PAXTON | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3034432277 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | DD7824 | 01 | CO | RAILROAD MEDICARE | OTHER |