Provider Demographics
NPI:1982387981
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:Other Name
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:970-624-4443
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:
Mailing Address - Fax:
Practice Address - Street 1:175 INVERNESS DR W STE 300
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80112-5069
Practice Address - Country:US
Practice Address - Phone:303-265-3390
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POUDRE VALLEY MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-08-08
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No261QR0404XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Cardiac FacilitiesGroup - Multi-Specialty