Healthcare Provider Details

I. General information

NPI: 1003514639
Provider Name (Legal Business Name): INTERMOUNTAIN MEDICAL GROUP DENVER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2023
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 EXEMPLA CIR STE 300
LAFAYETTE CO
80026-3384
US

IV. Provider business mailing address

500 ELDORADO BLVD STE 4300
BROOMFIELD CO
80021-3564
US

V. Phone/Fax

Practice location:
  • Phone: 303-673-1390
  • Fax: 720-627-6407
Mailing address:
  • Phone: 303-272-0566
  • Fax: 303-272-0390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

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