Basic Information
| Provider Information | |||||||||
| NPI: | 1083799928 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOULDER COMMUNITY HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BOULDER COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 BALSAM AVE | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803043404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034402273 | ||||||||
| FaxNumber: | 3034402435 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 BALSAM AVE | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803043404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034402273 | ||||||||
| FaxNumber: | 3034402435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 06/03/2014 | ||||||||
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| AuthorizedOfficialLastName: | WOODARD | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTRACTING & PROVIDER RELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3039383295 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 0909 | CO | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 2084P0800X | 0909 | CO | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0802X | 0909 | CO | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | 207P00000X | 0909 | CO | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 04073086 | 05 | CO | MEDICAID |