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General NPI Number Information
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NPI Number | 1538790704
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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 | 01/28/2020
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Last Update Date | 08/01/2024
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Provider Practice Location Address
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Address Line | 1000 POLE CREEK XING
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City | SIDNEY
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State | NE
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Zip | 69162-2901
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Country | US
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Telephone | 308-254-8525
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Fax | 308-254-4003
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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 | 308-254-8525
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0001X
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Taxonomy Name | Clinical Cardiac Electrophysiology 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 | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number |
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License Number State |
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