MEDICARE: INTERMOUNTAIN MEDICAL GROUP GRAND JUNCTION, 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	101YP2500X	Professional Counselor
2	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1972178051
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERMOUNTAIN MEDICAL GROUP GRAND JUNCTION, LLC

Provider Business Mailing Address
First Line	:	500 ELDORADO BLVD STE 6300
Second Line	:
City	:	BROOMFIELD
State	:	CO
Zip	:	80021-3422
Country	:	US
Telephone Number	:	303-272-0566
Fax Number	:	303-272-0390

Provider Business Practice Location Address
First Line	:	2570 PATTERSON RD
Second Line	:
City	:	GRAND JUNCTION
State	:	CO
Zip	:	81505-1438
Country	:	US
Telephone Number	:	970-298-6601
Fax Number	:	970-298-6641

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

Provider Enumeration Date	:	05/21/2021
Last Update Date	:	06/28/2024

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