Provider Demographics
NPI:1811976186
Name:BOULDER FAMILY PRACTICE CLINIC
Entity type:Organization
Organization Name:BOULDER FAMILY PRACTICE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-996-6804
Mailing Address - Street 1:1000 ALPINE AVE
Mailing Address - Street 2:#220
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-3406
Mailing Address - Country:US
Mailing Address - Phone:303-996-6804
Mailing Address - Fax:303-996-6807
Practice Address - Street 1:1000 ALPINE AVE
Practice Address - Street 2:#220
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3406
Practice Address - Country:US
Practice Address - Phone:303-996-6804
Practice Address - Fax:303-996-6807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-13
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18572207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO56530544Medicaid
CO56530544Medicaid
COD23462Medicare UPIN