Basic Information
| Provider Information | |||||||||
| NPI: | 1174179964 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOULDER COMMUNITY HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BCH URGENT CARE - ERIE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9049 | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803019049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034155810 | ||||||||
| FaxNumber: | 3034155820 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 ERIE PKWY STE 101 | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805164071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034155810 | ||||||||
| FaxNumber: | 3034155820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2019 | ||||||||
| 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 | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.