Provider Demographics
NPI:1881207660
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:CREDENTIALING MANAGER
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:970-624-4443
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:719-364-4141
Mailing Address - Fax:719-364-4140
Practice Address - Street 1:595 CHAPEL HILLS DR STE 325
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-1061
Practice Address - Country:US
Practice Address - Phone:719-364-4141
Practice Address - Fax:719-364-4140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-31
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty