MEDICARE: PLATTE 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	207V00000X	Obstetrics & Gynecology Physician

General Provider Information

NPI Number	:	1780208066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLATTE VALLEY MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	1606 PRAIRIE CENTER PKWY STE 350
Second Line	:
City	:	BRIGHTON
State	:	CO
Zip	:	80601-4005
Country	:	US
Telephone Number	:	303-498-3440
Fax Number	:	303-498-3445

Provider Business Practice Location Address
First Line	:	1606 PRAIRIE CENTER PKWY STE 350
Second Line	:
City	:	BRIGHTON
State	:	CO
Zip	:	80601-4005
Country	:	US
Telephone Number	:	303-498-3440
Fax Number	:	303-498-3445

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

Provider Enumeration Date	:	06/03/2020
Last Update Date	:	10/17/2023

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