Provider Demographics
NPI:1689445702
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:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JANA
Authorized Official - Middle Name:
Authorized Official - Last Name:CONROY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-624-1800
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:
Mailing Address - Fax:
Practice Address - Street 1:2750 BROADWAY ST STE 2178
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3573
Practice Address - Country:US
Practice Address - Phone:970-624-1800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POUDRE VALLEY MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-01-09
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty