=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174118145
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALPINE WOODS MEDICAL, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2021
-----------------------------------------------------
Last Update Date | 03/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6525 GUNPARK DR STE 370-202
-----------------------------------------------------
City | BOULDER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80301-3346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-799-7473
-----------------------------------------------------
Fax | 720-293-1122
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6525 GUNPARK DR STE 370-202
-----------------------------------------------------
City | BOULDER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80301-3346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-799-7473
-----------------------------------------------------
Fax | 720-293-1122
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRIMARY CARE PROVIDER
-----------------------------------------------------
Name | ERIC HERNANDEZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 720-799-7473
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------