Healthcare Provider Details

I. General information

NPI: 1497349260
Provider Name (Legal Business Name): POUDRE VALLEY MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2021
Last Update Date: 02/23/2021
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 SIGNAL TREE DR STE 1200
TIMNATH CO
80547-4908
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 970-237-7415
  • Fax: 970-237-7420
Mailing address:
  • Phone: 303-860-7770
  • Fax: 303-860-7775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

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