Healthcare Provider Details

I. General information

NPI: 1346862372
Provider Name (Legal Business Name): POUDRE VALLEY MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 05/13/2020
Certification Date: 05/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16222 W US HIGHWAY 24 STE 220
WOODLAND PARK CO
80863-8763
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 719-365-7300
  • Fax: 719-365-7301
Mailing address:
  • Phone: 719-365-7300
  • Fax: 719-365-7301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

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