Basic Information
| Provider Information | |||||||||
| NPI: | 1891756813 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOULDER RADIOLOGISTS INC P C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 42 GARDEN CTR | ||||||||
| Address2: | |||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800201730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034650401 | ||||||||
| FaxNumber: | 3034381351 | ||||||||
| Practice Location | |||||||||
| Address1: | 4747 ARAPAHOE AVE | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803031131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034737500 | ||||||||
| FaxNumber: | 3034402168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 03/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | NICHOLS | ||||||||
| AuthorizedOfficialFirstName: | ROGER | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3034737500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 03/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | CO | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 04995049 | 05 | CO | MEDICAID | CS6650 | 01 | CO | MEDICARE RAILROAD | OTHER |