Provider Demographics
NPI:1275020786
Name:POUDRE VALLEY MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:POUDRE VALLEY MEDICAL GROUP, LLC
Other - Org Name:UCHEALTH MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JANA
Authorized Official - Middle Name:
Authorized Official - Last Name:CONROY
Authorized Official - Suffix:
Authorized Official - Credentials:RHIA
Authorized Official - Phone:970-624-4443
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:720-733-5260
Mailing Address - Fax:720-733-5290
Practice Address - Street 1:4404 BARRANCA LN UNIT 101
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-7432
Practice Address - Country:US
Practice Address - Phone:720-733-5260
Practice Address - Fax:720-733-5290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-19
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Multi-Specialty