=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316733751
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POUDRE VALLEY MEDICAL GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2025
-----------------------------------------------------
Last Update Date | 04/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 N GRAND AVE STE 520
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81003-2757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-562-2360
-----------------------------------------------------
Fax | 719-562-2399
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2695 ROCKY MOUNTAIN AVE STE 150
-----------------------------------------------------
City | LOVELAND
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80538-9071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF CREDENTIALING
-----------------------------------------------------
Name | JANA CONROY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 719-562-2360
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------