Healthcare Provider Details

I. General information

NPI: 1659031748
Provider Name (Legal Business Name): POUDRE VALLEY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2021
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4660 YOSEMITE ST SUITE 100
DENVER CO
80238-4481
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 720-516-8902
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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 Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JANA CONROY
Title or Position: DIRECTOR OF CREDENTIALING
Credential:
Phone: 720-516-8902