Creekside Physical Medicine PLLC
Organization Active NPI Neuromusculoskeletal Medicine & OMM Physician · Boulder, CO
NPI 1578601969 · NPPES record last updated Aug 4, 2025
Key facts
- NPI
- 1578601969
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Neuromusculoskeletal Medicine & OMM Physician 204D00000X
- License
- 38635 (CO)
- Legal business name
- CREEKSIDE PHYSICAL MEDICINE PLLC
- Practice address
- 5387 Manhattan Cir
Ste 201
Boulder, CO 80303-4284 - Phone
- (303) 494-2705
- Fax
- (303) 494-2706
- NPI assigned
- Feb 1, 2007
- Organization subpart
- No
Authorized official
- Name
- David E Tanner, D.O
- Title
- Principal Clinician
- Phone
- (303) 494-2705
Subparts reporting this organization as parent 1
Practitioners 12
-
Daniel Fettig, PA
-
Haley Kershaw, PA-C
-
Leah Albano, PA-C
-
Mollie M Bradmon, PA-C
-
Diane Rachel Friedman, PA-C
-
Dara Pitts, PA-C
-
Rachel Savanna Povilus, PA-C
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in CO
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20070215000611 | CO | Part B Supplier - Clinic/Group Practice | 1658373923 |
Receives reassigned benefits from 11 practitioners Practice locations: Boulder, CO; Longmont, CO |
National Provider Directory
Locations
5387 Manhattan Cir
Ste 201
Boulder, CO 80303
Phone (303) 494-2705
600 S Airport Rd
Ste Gh
Longmont, CO 80503
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Neuromusculoskeletal Medicine & OMM Physician |
204D00000X | 38635 | CO | Yes |
Addresses
Primary practice location
5387 Manhattan Cir
Ste 201
Boulder, CO 80303-4284
Mailing address
5387 Manhattan Cir
Ste 201
Boulder, CO 80303-4284
Phone (303) 494-2705
Other providers in Boulder, CO
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- Shyamaa Marie Creaven
- Darrell Joseph Creekmore
- Kellie Susan Cremer
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- Jamie Marie Cribbs
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All providers in Boulder, CO · Neuromusculoskeletal Medicine & OMM Physician in Colorado
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 4, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.