Healthcare Provider Details

I. General information

NPI: 1518465137
Provider Name (Legal Business Name): POUDRE VALLEY MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2018
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CENTRAL PARK DR STE 1050
STEAMBOAT SPRINGS CO
80487-8818
US

IV. Provider business mailing address

2695 ROCKY MOUNTAIN AVE STE 150
LOVELAND CO
80538-9071
US

V. Phone/Fax

Practice location:
  • Phone: 970-870-1035
  • Fax: 970-870-1036
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JANA CONROY
Title or Position: DIRECTOR OF CREDENTIALING
Credential: MBA, RHIA
Phone: 970-870-1035