Healthcare Provider Details

I. General information

NPI: 1871106054
Provider Name (Legal Business Name): INTERMOUNTAIN MEDICAL GROUP GRAND JUNCTION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2020
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2643 PATTERSON RD STE 603
GRAND JUNCTION CO
81506-1937
US

IV. Provider business mailing address

2643 PATTERSON RD STE 603
GRAND JUNCTION CO
81506-1937
US

V. Phone/Fax

Practice location:
  • Phone: 970-298-7440
  • Fax: 970-298-7459
Mailing address:
  • Phone: 970-298-7440
  • Fax: 970-298-7459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

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