Basic Information
| Provider Information | |||||||||
| NPI: | 1134150162 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOULDER VALLEY PULMONOLOGY | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1155 ALPINE AVE STE 150 | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803043400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034422150 | ||||||||
| FaxNumber: | 3034423363 | ||||||||
| Practice Location | |||||||||
| Address1: | 1155 ALPINE AVE STE 150 | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803043400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034422150 | ||||||||
| FaxNumber: | 3034423363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 07/02/2013 | ||||||||
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| AuthorizedOfficialLastName: | BJERKE | ||||||||
| AuthorizedOfficialFirstName: | RANDAL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3034422150 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 57476748 | 05 | CO | MEDICAID | 13352 | 01 | CO | BCBS PRACTICE ID | OTHER |