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General NPI Number Information
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NPI Number | 1710593611
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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 | 09/17/2020
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Last Update Date | 12/08/2025
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Provider Practice Location Address
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Address Line | 1024 S LEMAY AVE
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City | FORT COLLINS
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State | CO
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Zip | 80524-3929
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Country | US
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Telephone | 970-495-8440
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Fax | 970-495-7644
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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 | 970-495-8440
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WW0000X
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Taxonomy Name | Wound Care Registered Nurse
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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 | 261Q00000X
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Taxonomy Name | Clinic/Center
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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 | 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 #6
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #8
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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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Taxonomy #9
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #10
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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 #11
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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