Healthcare Provider Details

I. General information

NPI: 1154563807
Provider Name (Legal Business Name): BOULDER CANCER CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2009
Last Update Date: 03/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 ALPINE AVE
BOULDER CO
80304-3305
US

IV. Provider business mailing address

905 ALPINE AVE
BOULDER CO
80304-3305
US

V. Phone/Fax

Practice location:
  • Phone: 303-448-4620
  • Fax: 303-449-5807
Mailing address:
  • Phone: 303-448-4620
  • Fax: 303-449-5807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number200946901
License Number StateCO

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. KEVIN LAWERANCE SCHEWE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 303-448-4620