Healthcare Provider Details

I. General information

NPI: 1124632534
Provider Name (Legal Business Name): INTERMOUNTAIN MEDICAL GROUP DENVER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2020
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2823 ROSLYN ST
DENVER CO
80238-2624
US

IV. Provider business mailing address

2823 ROSLYN ST
DENVER CO
80238-2624
US

V. Phone/Fax

Practice location:
  • Phone: 303-403-6333
  • Fax: 303-403-6333
Mailing address:
  • Phone: 303-403-6333
  • Fax: 303-403-6325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

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