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General NPI Number Information
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NPI Number | 1225847460
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Entity Type | Organization
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Legal Business Name | POUDRE VALLEY MEDICAL GROUP, LLC
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Dates
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Enumeration Date | 01/02/2025
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Last Update Date | 04/21/2025
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Provider Practice Location Address
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Address Line | 400 W 16TH ST
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City | PUEBLO
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State | CO
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Zip | 81003-2745
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Country | US
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Telephone | 719-584-4921
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Fax | 719-595-7994
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Provider Business Mailing Address
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Address Line | 2695 ROCKY MOUNTAIN AVE STE 150
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City | LOVELAND
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State | CO
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Zip | 80538-9071
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF CREDENTIALING
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Name | JANA CONROY
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Credential |
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Telephone | 719-584-4921
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207RH0002X
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Taxonomy Name | Hospice and Palliative Medicine (Internal Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 208M00000X
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Taxonomy Name | Hospitalist Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QE0002X
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Taxonomy Name | Emergency Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 363LN0000X
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Taxonomy Name | Neonatal Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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