Healthcare Provider Details

I. General information

NPI: 1366763260
Provider Name (Legal Business Name): POUDRE VALLEY MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2010
Last Update Date: 11/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2695 ROCKY MOUNTAIN AVE SUITE 150
LOVELAND CO
80538-8702
US

IV. Provider business mailing address

2695 ROCKY MOUNTAIN AVE SUITE 150
LOVELAND CO
80538-8702
US

V. Phone/Fax

Practice location:
  • Phone: 970-624-4420
  • Fax: 970-624-4459
Mailing address:
  • Phone: 970-624-4420
  • Fax: 970-624-4459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number StateNULL
# 7
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: JANA CONROY
Title or Position: CREDENTIALING MANAGER
Credential: RHIA
Phone: 970-624-4443