Healthcare Provider Details

I. General information

NPI: 1215774542
Provider Name (Legal Business Name): INTERMOUNTAIN MEDICAL GROUP DENVER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2024
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12905 W 40TH AVE, STE 430
WHEAT RIDGE CO
80401
US

IV. Provider business mailing address

500 ELDORADO BLVD STE 4300
BROOMFIELD CO
80021-3564
US

V. Phone/Fax

Practice location:
  • Phone: 303-265-5770
  • Fax:
Mailing address:
  • Phone: 303-272-0566
  • Fax: 303-272-0390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number State

VIII. Authorized Official

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