Provider Demographics
| NPI: | 1356765556 |
|---|---|
| Name: | INTERMOUNTAIN MEDICAL GROUP GRAND JUNCTION, LLC |
| Entity type: | Organization |
| Organization Name: | INTERMOUNTAIN MEDICAL GROUP GRAND JUNCTION, LLC |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | VP FINANCE |
| Authorized Official - Prefix: | MR |
| Authorized Official - First Name: | JON |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | MCDANIEL |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 303-272-0231 |
| Mailing Address - Street 1: | 2635 N 7TH ST |
| Mailing Address - Street 2: | |
| Mailing Address - City: | GRAND JUNCTION |
| Mailing Address - State: | CO |
| Mailing Address - Zip Code: | 81501-8209 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 970-298-2273 |
| Mailing Address - Fax: | 970-298-1809 |
| Practice Address - Street 1: | 2635 N 7TH ST |
| Practice Address - Street 2: | |
| Practice Address - City: | GRAND JUNCTION |
| Practice Address - State: | CO |
| Practice Address - Zip Code: | 81501 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 970-298-2273 |
| Practice Address - Fax: | 970-298-1809 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | SISTERS OF CHARITY OF LEAVENWORTH HEALTH SYSTEM |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2014-02-07 |
| Last Update Date: | 2024-06-28 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 207Q00000X, 207R00000X, 207RH0003X, 207RN0300X, 207RI0200X, 207T00000X, 207VM0101X, 208100000X, 208200000X, 2083X0100X, 2080P0202X, 2086S0120X, 208G00000X, 207X00000X | ||
| CO | 207V00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Single Specialty | |
| No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207RH0003X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | Group - Multi-Specialty |
| No | 207RN0300X | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | Group - Multi-Specialty |
| No | 207RI0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | Group - Multi-Specialty |
| No | 207T00000X | Allopathic & Osteopathic Physicians | Neurological Surgery | Group - Multi-Specialty | |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 207VM0101X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | Group - Multi-Specialty |
| No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
| No | 208200000X | Allopathic & Osteopathic Physicians | Plastic Surgery | Group - Multi-Specialty | |
| No | 2083X0100X | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine | Group - Multi-Specialty |
| No | 2080P0202X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | Group - Multi-Specialty |
| No | 2086S0120X | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery | Group - Multi-Specialty |
| No | 208G00000X | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | Group - Multi-Specialty |
