Provider Demographics
NPI:1649883547
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 MEDICAL GROUP
Authorized Official - Prefix:
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 1:450 WILLIAMS WAY
Mailing Address - Street 2:
Mailing Address - City:MOAB
Mailing Address - State:UT
Mailing Address - Zip Code:84532-2185
Mailing Address - Country:US
Mailing Address - Phone:435-719-3500
Mailing Address - Fax:435-719-3529
Practice Address - Street 1:450 WILLIAMS WAY
Practice Address - Street 2:
Practice Address - City:MOAB
Practice Address - State:UT
Practice Address - Zip Code:84532-2185
Practice Address - Country:US
Practice Address - Phone:435-719-3500
Practice Address - Fax:435-719-3529
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTERMOUNTAIN FRONT RANGE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-08-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty