Basic Information
Provider Information | |||||||||
NPI: | 1275283574 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PLATTE VALLEY MEDICAL GROUP, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 500 ELDORADO BLVD STE 4300 | ||||||||
Address2: |   | ||||||||
City: | BROOMFIELD | ||||||||
State: | CO | ||||||||
PostalCode: | 800213564 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 217 N 50TH AVE | ||||||||
Address2: |   | ||||||||
City: | BRIGHTON | ||||||||
State: | CO | ||||||||
PostalCode: | 806018364 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3036591152 | ||||||||
FaxNumber: | 7206850027 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/28/2022 | ||||||||
LastUpdateDate: | 03/28/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCDANIEL | ||||||||
AuthorizedOfficialFirstName: | JON | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
AuthorizedOfficialTelephone: | 3032720231 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | BRIGHTON COMMUNITY HOSPITAL ASSOCIATION | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/15/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.