Provider Demographics
NPI:1730267949
Name:BOULDER VALLEY THORACIC AND CARDIOVASCULAR SURGERY
Entity type:Organization
Organization Name:BOULDER VALLEY THORACIC AND CARDIOVASCULAR SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:B
Authorized Official - Last Name:DOUTHIT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-652-8888
Mailing Address - Street 1:6800 N 79TH ST
Mailing Address - Street 2:SUITE # 203
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-7042
Mailing Address - Country:US
Mailing Address - Phone:303-652-8888
Mailing Address - Fax:303-652-2720
Practice Address - Street 1:6800 N 79TH ST
Practice Address - Street 2:SUITE # 203
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-7042
Practice Address - Country:US
Practice Address - Phone:303-652-8888
Practice Address - Fax:303-652-2720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO33880280Medicaid
CO33880280Medicaid