=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235229915
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN BOACKLE CHILDRESS MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2006
-----------------------------------------------------
Last Update Date | 12/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3601 S PENNSYLVANIA ST STE B
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80113-3753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-262-2462
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2275 HUDSON ST
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80207-3846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-231-4567
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | H7909
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | 335634
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | 35598
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | CDRH.0035598
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | MD.43902
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------