Basic Information
| Provider Information | |||||||||
| NPI: | 1760947832 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POUDRE VALLEY MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | UCHEALTH MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2695 ROCKY MOUNTAIN AVE STE 150 | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805389071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705862343 | ||||||||
| FaxNumber: | 9705869060 | ||||||||
| Practice Location | |||||||||
| Address1: | 131 STANLEY AVE STE 202 | ||||||||
| Address2: | |||||||||
| City: | ESTES PARK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805176356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705862343 | ||||||||
| FaxNumber: | 9705869060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2019 | ||||||||
| LastUpdateDate: | 01/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | CONROY | ||||||||
| AuthorizedOfficialFirstName: | JANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 9706244443 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MBA, RHIA | ||||||||
| NPICertificationDate: | 01/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01657356 | 05 | CO | MEDICAID |