NPIMap

Organization Active NPI

Creekside Physical Medicine PLLC

  • Neuromusculoskeletal Medicine & OMM Physician
  • Boulder, CO
National Provider Identifier
1578601969
Registry record updated Aug 4, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Neuromusculoskeletal Medicine & OMM PhysicianTaxonomy code 204D00000X
License
38635 Issued in 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
Last updated
Aug 4, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 4, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
David E Tanner, D.ONPI 1609897578
Title
Principal Clinician
Phone
(303) 494-2705

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Neuromusculoskeletal Medicine & OMM PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 204D00000X 38635 CO Primary

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

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CO

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20070215000611 CO Part B Supplier - Clinic/Group Practice 1658373923 Receives reassigned benefits from 11 practitioners
Practice locations: Boulder, CO; Longmont, CO

National Provider Directory

National Provider Directory

Locations

600 S Airport Rd
Bldg D
Longmont, CO 80503
Phone (303) 494-2705

600 S Airport Rd
Ste Gh
Longmont, CO 80503

Ownership & related parties

Subparts reporting this organization as parent 1

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

Practitioners & affiliated clinicians

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1170288000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1754265600000",
    "number": "1578601969",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5387 MANHATTAN CIR",
            "address_2": "STE 201",
            "city": "BOULDER",
            "state": "CO",
            "postal_code": "803034284",
            "telephone_number": "303-494-2705",
            "fax_number": "303-494-2706"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5387 MANHATTAN CIR",
            "address_2": "STE 201",
            "city": "BOULDER",
            "state": "CO",
            "postal_code": "803034284",
            "telephone_number": "303-494-2705",
            "fax_number": "303-494-2706"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CREEKSIDE PHYSICAL MEDICINE PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-01",
        "last_updated": "2025-08-04",
        "certification_date": "2025-08-04",
        "status": "A",
        "authorized_official_last_name": "TANNER",
        "authorized_official_first_name": "DAVID",
        "authorized_official_middle_name": "E",
        "authorized_official_title_or_position": "PRINCIPAL CLINICIAN",
        "authorized_official_telephone_number": "303-494-2705",
        "authorized_official_credential": "D.O"
    },
    "taxonomies": [
        {
            "code": "204D00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Neuromusculoskeletal Medicine & OMM",
            "state": "CO",
            "license": "38635",
            "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 Aug 4, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.