| Organization Name: | CREEKSIDE PHYSICAL MEDICINE PLLC |
| NPI Number: | 1578601969 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | DAVID E TANNER (PRINCIPAL CLINICIAN) |
| Mailing Address: | 5387 Manhattan Cir Ste 201 Boulder |
| State: | CO US |
| Postal Code: | 803034284 |
| Phone Number: | 3034942705 |
| Fax Number: | 3034942706 |
| NPI Enumeration Date: | 02/01/2007 |
| NPI Last Update Date: | 12/12/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 204D00000X |
| License Number: | 38635 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CO |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | Neuromusculoskeletal Medicine & OMM |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |