Healthcare Provider Details

I. General information

NPI: 1225669450
Provider Name (Legal Business Name): POUDRE VALLEY MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2020
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 RUSSELL ST
CRAIG CO
81625-1920
US

IV. Provider business mailing address

2695 ROCKY MOUNTAIN AVE STE 150
LOVELAND CO
80538-9071
US

V. Phone/Fax

Practice location:
  • Phone: 970-824-1020
  • Fax: 970-824-5300
Mailing address:
  • Phone: 970-824-1020
  • Fax: 970-824-5300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JANA CONROY
Title or Position: DIRECTOR OF CREDENTIALING
Credential:
Phone: 970-824-1020