Provider Demographics
NPI:1417993916
Name:POUDRE VALLEY INTERNISTS PC
Entity Type:Organization
Organization Name:POUDRE VALLEY INTERNISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCANN-STOECKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-482-3712
Mailing Address - Street 1:4674 SNOW MESA DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-8615
Mailing Address - Country:US
Mailing Address - Phone:970-482-3712
Mailing Address - Fax:970-482-4057
Practice Address - Street 1:4674 SNOW MESA DR
Practice Address - Street 2:STE 100
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-8615
Practice Address - Country:US
Practice Address - Phone:970-482-3712
Practice Address - Fax:970-482-4057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO06D0911568OtherCLIA
NE10025031400Medicaid
WY117631500Medicaid
CO05675839Medicaid
NE10025031400Medicaid
CO05675839Medicaid