MEDICARE: POUDRE VALLEY MEDICAL GROUP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician

General Provider Information

NPI Number	:	1861198038
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POUDRE VALLEY MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	2695 ROCKY MOUNTAIN AVE STE 150
Second Line	:
City	:	LOVELAND
State	:	CO
Zip	:	80538-9071
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1370 INTERQUEST PKWY
Second Line	:	SUITE 300
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80921-4340
Country	:	US
Telephone Number	:	719-477-0211
Fax Number	:	719-477-0501

Authorized Official
Title or Position	:	DIRECTOR OF CREDENTIALING
Name	:	JANA CONROY
Credential	:
Telephone Number	:	719-477-0211

Provider Enumeration Date	:	01/31/2023
Last Update Date	:	08/19/2024

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