Provider Demographics
NPI: | 1275171977 |
---|---|
Name: | POUDRE VALLEY MEDICAL GROUP, LLC |
Entity Type: | Organization |
Organization Name: | POUDRE VALLEY MEDICAL GROUP, LLC |
Other - Org Name: | |
Other - Org Type: | |
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: | 970-624-4443 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2773 JANITELL RD |
Practice Address - Street 2: | |
Practice Address - City: | COLORADO SPRINGS |
Practice Address - State: | CO |
Practice Address - Zip Code: | 80906-4102 |
Practice Address - Country: | US |
Practice Address - Phone: | 719-365-6840 |
Practice Address - Fax: | 719-365-6774 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2019-12-13 |
Last Update Date: | 2019-12-13 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 2083X0100X | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine | Group - Single Specialty |