{
"Npi": {
"NPI": "1134917826",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "Y",
"ParentOrgLBN": "INTERMOUNTAIN FRONT RANGE, INC.",
"ParentOrgTIN": null,
"OrgName": "INTERMOUNTAIN MEDICAL GROUP DENVER, LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "500 ELDORADO BLVD STE 4300",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "BROOMFIELD",
"MailingAddressStateName": "CO",
"MailingAddressPostalCode": "80021-3564",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "303-272-0566",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "12905 W 40TH AVE",
"SecondLinePracticeLocationAddress": "SUILTE 505",
"PracticeLocationAddressCityName": "WHEAT RIDGE",
"PracticeLocationAddressStateName": "CO",
"PracticeLocationAddressPostalCode": "80401-2794",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "303-265-5470",
"PracticeLocationAddressFaxNumber": "303-325-8516",
"EnumerationDate": "04/30/2025",
"LastUpdateDate": "04/30/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MCDANIEL",
"AuthorizedOfficialFirstName": "JON",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "VP FINANCE",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "303-272-0231",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "163WW0000X",
"TaxonomyName": "Wound Care Registered Nurse",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "2083P0011X",
"TaxonomyName": "Undersea and Hyperbaric Medicine (Preventive Medicine) Physician",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "207PE0005X",
"TaxonomyName": "Undersea and Hyperbaric Medicine (Emergency Medicine) Physician",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": [
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
]
}
}
}