MEDICARE: POUDRE VALLEY MEDICAL GROUP, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician

General Provider Information

NPI Number	:	1306557905
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POUDRE VALLEY MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	2695 ROCKY MOUNTAIN AVE STE 150
Second Line	:
City	:	LOVELAND
State	:	CO
Zip	:	80538-9071
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1370 INTERQUEST PARKWAY
Second Line	:	SUITE 100
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80921-4338
Country	:	US
Telephone Number	:	719-365-1950
Fax Number	:	719-364-5639

Authorized Official
Title or Position	:	DIRECTOR OF CREDENTIALING
Name	:	JANA CONROY
Credential	:
Telephone Number	:	719-365-1950

Provider Enumeration Date	:	12/06/2022
Last Update Date	:	07/15/2024

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