Active NPI
K2 Dermatology, LLC
- Dermatology Physician
- Boulder, CO
National Provider Identifier
1558094003
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dermatology Physician
- Legal business name
- K2 DERMATOLOGY, LLC
- Practice address
- 3434 47TH St Ste 200
Boulder, CO 80301-1817 - Phone
- (303) 444-8100
- NPI assigned
- Jul 1, 2022
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Ivy Bradshaw Koger
- Title
- Practice Manager
- Phone
- (303) 579-5929
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dermatology Physician | 207N00000X | Primary |
Addresses
Primary practice location
3434 47TH St Ste 200
Boulder, CO 80301-1817
Mailing address
1165 Linden Cir
Boulder, CO 80304-0743
Phone (303) 579-5929
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in CO
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20221129000030 | CO | Part B Supplier - Clinic/Group Practice | 9638547474 |
Receives reassigned benefits from 8 practitioners Practice locations: Boulder, CO |
Laboratory certificates & supplier records
Derived by NPIMapThese CMS records do not include an NPI. They are shown because their name and street address match this provider’s.
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 06D1049848 | K2 Dermatology | Compliance | Jul 31, 2026 |
National Provider Directory
National Provider DirectoryPractitioners & affiliated clinicians
Practitioners 8
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1656633600000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1656633600000",
"number": "1558094003",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1165 LINDEN CIR",
"city": "BOULDER",
"state": "CO",
"postal_code": "803040743",
"telephone_number": "303-579-5929"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3434 47TH ST STE 200",
"city": "BOULDER",
"state": "CO",
"postal_code": "803011817",
"telephone_number": "303-444-8100"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "K2 DERMATOLOGY, LLC",
"organizational_subpart": "NO",
"enumeration_date": "2022-07-01",
"last_updated": "2022-07-01",
"certification_date": "2022-06-13",
"status": "A",
"authorized_official_last_name": "KOGER",
"authorized_official_first_name": "IVY",
"authorized_official_middle_name": "BRADSHAW",
"authorized_official_title_or_position": "PRACTICE MANAGER",
"authorized_official_telephone_number": "303-579-5929"
},
"taxonomies": [
{
"code": "207N00000X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Dermatology",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Boulder, CO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 1, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.