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NPI Code Detail

MEDICARE: POUDRE VALLEY MEDICAL GROUP, LLC

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
1207Q00000XFamily Medicine Physician

General Provider Information

NPI Number : 1568075893
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 : 320 E FONTANERO ST STE 100
Second Line :
City : COLORADO SPRINGS
State : CO
Zip : 80907-7535
Country : US
Telephone Number : 719-365-7420
Fax Number : 719-365-7421
Authorized Official
Title or Position : DIRECTOR OF CREDENTIALING
Name : JANA CONROY
Credential :
Telephone Number : 719-365-7420
Provider Enumeration Date : 08/26/2020
Last Update Date : 08/01/2024

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Directions to “POUDRE VALLEY MEDICAL GROUP, LLC ” Practice Location

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