=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588817464
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOULDER ENDOCRINOLOGY PHYSICIANS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2008
-----------------------------------------------------
Last Update Date | 07/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 892 W SOUTH BOULDER RD
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80027-2453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-586-5200
-----------------------------------------------------
Fax | 303-586-5201
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 892 W SOUTH BOULDER RD
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80027-2453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-586-5200
-----------------------------------------------------
Fax | 303-586-5201
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | M.D.
-----------------------------------------------------
Name | KELLY A. MANDAGERE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 303-586-5200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number | 45001
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------