Healthcare Provider Details

I. General information

NPI: 1194071605
Provider Name (Legal Business Name): BOULDER GYNECOLOGY & MINIMALLY INVASIVE SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2012
Last Update Date: 08/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 RIVERBEND RD SUITE 200
BOULDER CO
80301-2636
US

IV. Provider business mailing address

4800 RIVERBEND RD SUITE 200
BOULDER CO
80301-2636
US

V. Phone/Fax

Practice location:
  • Phone: 720-382-2621
  • Fax: 720-382-2625
Mailing address:
  • Phone: 720-382-2621
  • Fax: 720-382-2625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number43874
License Number StateCO

VIII. Authorized Official

Name: LISA LEPINE
Title or Position: PRESIDENT/OWNER
Credential: M.D.
Phone: 720-382-2621