MEDICARE: BOULDER VALLEY GASTROENTEROLOGY INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician

General Provider Information

NPI Number	:	1134715360
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOULDER VALLEY GASTROENTEROLOGY INC.

Provider Business Mailing Address
First Line	:	382 S ARTHUR AVE
Second Line	:
City	:	LOUISVILLE
State	:	CO
Zip	:	80027-3094
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1960 N OGDEN ST STE 210
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80218-3668
Country	:	US
Telephone Number	:	303-604-5000
Fax Number	:

Authorized Official
Title or Position	:	MD
Name	:	DAUS MAHNKE
Credential	:
Telephone Number	:	303-604-5000

Provider Enumeration Date	:	12/11/2020
Last Update Date	:	12/11/2020

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