Healthcare Provider Details

I. General information

NPI: 1962011650
Provider Name (Legal Business Name): INTERMOUNTAIN MEDICAL GROUP DENVER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2020
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1960 N OGDEN ST STE 110
DENVER CO
80218-3667
US

IV. Provider business mailing address

500 ELDORADO BLVD STE 6300
BROOMFIELD CO
80021-3422
US

V. Phone/Fax

Practice location:
  • Phone: 303-318-2460
  • Fax: 303-318-2489
Mailing address:
  • Phone: 303-272-0566
  • Fax: 303-272-0390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: JON MCDANIEL
Title or Position: VP FINANCE MGPS OPERATIONS
Credential:
Phone: 303-272-0231