Provider Demographics
NPI:1730261462
Name:BOULDER VALLEY PLASTIC SURGERY INC.
Entity type:Organization
Organization Name:BOULDER VALLEY PLASTIC SURGERY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:T
Authorized Official - Last Name:SWAIL
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:303-449-6666
Mailing Address - Street 1:2575 PEARL ST.
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302
Mailing Address - Country:US
Mailing Address - Phone:303-449-6666
Mailing Address - Fax:303-449-7023
Practice Address - Street 1:2575 PEARL ST.
Practice Address - Street 2:SUITE 300
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302
Practice Address - Country:US
Practice Address - Phone:303-449-6666
Practice Address - Fax:303-449-7023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO34276208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COSW88401OtherB/C AND B/S PROVIDER ID
CO01342765Medicaid