Healthcare Provider Details

I. General information

NPI: 1548874761
Provider Name (Legal Business Name): INTERMOUNTAIN MEDICAL GROUP DENVER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2020
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23770 E SMOKY HILL RD STE 240
AURORA CO
80016-3089
US

IV. Provider business mailing address

23770 E SMOKY HILL RD STE 240
AURORA CO
80016-3089
US

V. Phone/Fax

Practice location:
  • Phone: 303-812-6880
  • Fax: 303-812-5173
Mailing address:
  • Phone: 303-812-6880
  • Fax: 303-812-5173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JON MCDANIEL
Title or Position: VP FINANCE MEDICAL GROUP
Credential:
Phone: 303-272-0231