Healthcare Provider Details

I. General information

NPI: 1366337230
Provider Name (Legal Business Name): INTERMOUNTAIN MEDICAL GROUP DENVER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2025
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1027 N 27TH ST
BILLINGS MT
59101-0711
US

IV. Provider business mailing address

500 ELDORADO BLVD STE 4300
BROOMFIELD CO
80021-3564
US

V. Phone/Fax

Practice location:
  • Phone: 801-442-4122
  • Fax:
Mailing address:
  • Phone: 303-272-0566
  • Fax: 303-272-0390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number
License Number State

VIII. Authorized Official

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