NPIMap

Individual provider Active NPI

Bradley Wallace, M.D.

  • Surgery Physician
  • Colorado Springs, CO
National Provider Identifier
1881038115
Registry record updated Jun 23, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Surgery PhysicianTaxonomy code 208600000X
License
DR.0063071 Issued in CO
Practice address
1400 E Boulder St Ste 500
Colorado Springs, CO 80909-5533
Phone
(719) 364-6487
NPI assigned
Apr 17, 2013
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 23, 2022

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Surgery Physician 208600000X DR.0063071 CO Primary
Student in an Organized Health Care Education/Training Program 390200000X

Addresses

Primary practice location

1400 E Boulder St Ste 500
Colorado Springs, CO 80909-5533

Mailing address

2695 Rocky Mountain Ave Ste 150
Loveland, CO 80538-9071
Phone (719) 364-6487

Other practice location 1

13001 E. 17th Place
University of Colorado School of Medicine GME
Aurora, CO 80045-2581
Phone (303) 724-2680

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CO
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20220922002158 CO Practitioner - General Surgery 3375854490 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
General Surgery
Education
University of Texas Southwestern Medical School at Dallas, 2013
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Poudre Valley Medical Group LLCGroup PAC ID 9638208549, 2,425 clinicians

Practice addresses (Care Compare)

1400 E Boulder St
Suite 500 Ear Nose and Throat Clinic Mem Hosp
Colorado Springs, CO 80909-5533
Phone (719) 364-4120

Hospital & facility affiliations

  • Uch-Memorial Health System Hospital, Colorado Springs, CO, CCN 060022
  • Uchealth Grandview Hospital Hospital, Colorado Springs, CO, CCN 060130

Procedures performed for Medicare patients

ProcedureNumber of procedures
Hernia repair - groin (open)1-10
Upper gastrointestinal (GI) endoscopy for acid reflux1-10
Removal of tissue1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
DR.0063071COMDSurgery Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Poudre Valley Medical Group, LLC CurrentSince Aug 22, 2022 Accepting new patients
Poudre Valley Medical Group, LLC Surgery CurrentSince Aug 22, 2022 Accepting new patients
Uch-MHS Past Accepting new patients

Locations

4404 Barranca Ln
Castle Rock, CO 80104
Phone (720) 733-5260

1400 E Boulder St
Colorado Springs, CO 80909
Phone (719) 365-5120

8890 N Union Blvd
Colorado Springs, CO 80920
Phone (719) 364-5633

1400 E Boulder St
Ste 500
Colorado Springs, CO 80909
Phone (719) 364-6487

1400 E Boulder St
Ste 500EAR
Colorado Springs, CO 80909
Phone (719) 364-4120

2695 Rocky Mountain Ave
Ste 150
Loveland, CO 80538
Phone (970) 624-2412

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 19

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 19

NPI Registry JSON

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

{
    "created_epoch": "1366156800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1655942400000",
    "number": "1881038115",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2695 ROCKY MOUNTAIN AVE STE 150",
            "city": "LOVELAND",
            "state": "CO",
            "postal_code": "805389071",
            "telephone_number": "719-364-6487"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1400 E BOULDER ST STE 500",
            "city": "COLORADO SPRINGS",
            "state": "CO",
            "postal_code": "809095533",
            "telephone_number": "719-364-6487"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "13001 E. 17th Place",
            "address_2": "University of Colorado School of Medicine GME",
            "address_purpose": "LOCATION",
            "city": "Aurora",
            "state": "CO",
            "postal_code": "800452581",
            "country_code": "US",
            "telephone_number": "303-724-2680",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "BRADLEY",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2013-04-17",
        "last_updated": "2022-06-23",
        "certification_date": "2022-06-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": "CO",
            "license": "DR.0063071",
            "primary": true
        },
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Colorado Springs, CO

Sources for this page

Verify at the official NPI Registry.