Healthcare Provider Details

I. General information

NPI: 1649883547
Provider Name (Legal Business Name): INTERMOUNTAIN MEDICAL GROUP GRAND JUNCTION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 WILLIAMS WAY
MOAB UT
84532-2185
US

IV. Provider business mailing address

450 WILLIAMS WAY
MOAB UT
84532-2185
US

V. Phone/Fax

Practice location:
  • Phone: 435-719-3500
  • Fax: 435-719-3529
Mailing address:
  • Phone: 435-719-3500
  • Fax: 435-719-3529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology 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: JON MCDANIEL
Title or Position: VP FINANCE MEDICAL GROUP
Credential:
Phone: 303-272-0231