Healthcare Provider Details

I. General information

NPI: 1205456035
Provider Name (Legal Business Name): POUDRE VALLEY MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3116 WILLETT DR
LARAMIE WY
82072-5048
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 307-742-9411
  • Fax: 307-742-9423
Mailing address:
  • Phone: 307-742-9411
  • Fax: 307-742-9423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JANA CONROY
Title or Position: DIRECTOR OF CREDENTIALING
Credential:
Phone: 307-742-9411