Healthcare Provider Details

I. General information

NPI: 1275251027
Provider Name (Legal Business Name): RUSHMORE ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2022
Last Update Date: 10/11/2022
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1942 BROADWAY STE 314C
BOULDER CO
80302-5233
US

IV. Provider business mailing address

1942 BROADWAY STE 314C
BOULDER CO
80302-5233
US

V. Phone/Fax

Practice location:
  • Phone: 720-202-8846
  • Fax:
Mailing address:
  • Phone: 720-202-8846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. SARAH MEDINA
Title or Position: CO-OWNER, PARTNER
Credential: CRNA
Phone: 720-202-8846