Healthcare Provider Details

I. General information

NPI: 1700273083
Provider Name (Legal Business Name): INTEGRATED MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2015
Last Update Date: 02/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2244 E HARMONY RD STE 110
FORT COLLINS CO
80528-3422
US

IV. Provider business mailing address

2244 E HARMONY RD STE 110
FORT COLLINS CO
80528-3422
US

V. Phone/Fax

Practice location:
  • Phone: 970-226-1117
  • Fax: 970-226-0251
Mailing address:
  • Phone: 970-226-1117
  • Fax: 970-226-0251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateCO

VIII. Authorized Official

Name: MS. TARRYN LEIGH FARRELL
Title or Position: CFO
Credential:
Phone: 970-226-1117