Healthcare Provider Details

I. General information

NPI: 1962270371
Provider Name (Legal Business Name): INTERMOUNTAIN MEDICAL GROUP DENVER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2023
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23750 E 14TH AVE SUITE 250
AURORA CO
80018-1973
US

IV. Provider business mailing address

500 ELDORADO BLVD STE 4300
BROOMFIELD CO
80021-3564
US

V. Phone/Fax

Practice location:
  • Phone: 303-812-5200
  • Fax: 303-272-0262
Mailing address:
  • Phone: 303-272-0566
  • Fax: 303-272-0390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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