Provider Demographics
NPI:1043251432
Name:BOULDER PLASTIC SURGERY PROF LLC
Entity type:Organization
Organization Name:BOULDER PLASTIC SURGERY PROF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PAXTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-443-2277
Mailing Address - Street 1:2525 4TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-3966
Mailing Address - Country:US
Mailing Address - Phone:303-443-2277
Mailing Address - Fax:303-443-7124
Practice Address - Street 1:2525 4TH ST
Practice Address - Street 2:STE 202
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3966
Practice Address - Country:US
Practice Address - Phone:800-462-0975
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CODD7824OtherRAILROAD MEDICARE
CODD7824OtherRAILROAD MEDICARE