MEDICARE: INTERMOUNTAIN MEDICAL GROUP DENVER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	163WW0000X	Wound Care Registered Nurse
2	2083P0011X	Undersea and Hyperbaric Medicine (Preventive Medicine) Physician
3	207PE0005X	Undersea and Hyperbaric Medicine (Emergency Medicine) Physician

General Provider Information

NPI Number	:	1134917826
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERMOUNTAIN MEDICAL GROUP DENVER, LLC

Provider Business Mailing Address
First Line	:	500 ELDORADO BLVD STE 4300
Second Line	:
City	:	BROOMFIELD
State	:	CO
Zip	:	80021-3564
Country	:	US
Telephone Number	:	303-272-0566
Fax Number	:

Provider Business Practice Location Address
First Line	:	12905 W 40TH AVE
Second Line	:	SUILTE 505
City	:	WHEAT RIDGE
State	:	CO
Zip	:	80401-2794
Country	:	US
Telephone Number	:	303-265-5470
Fax Number	:	303-325-8516

Authorized Official
Title or Position	:	VP FINANCE
Name	:	JON MCDANIEL
Credential	:
Telephone Number	:	303-272-0231

Provider Enumeration Date	:	04/30/2025
Last Update Date	:	04/30/2025

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