Basic Information
| Provider Information | |||||||||
| NPI: | 1104457431 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POUDRE VALLEY MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | UCHEALTH CANCER CARE AND HEMATOLOGY CLINIC - HUGO | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2695 ROCKY MOUNTAIN AVE STE 150 | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805389071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193656568 | ||||||||
| FaxNumber: | 7193656317 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 6TH ST | ||||||||
| Address2: | |||||||||
| City: | HUGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808212002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193656568 | ||||||||
| FaxNumber: | 7193656317 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2020 | ||||||||
| LastUpdateDate: | 04/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | CONROY | ||||||||
| AuthorizedOfficialFirstName: | JANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9706244443 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
No ID Information.