Basic Information
| Provider Information | |||||||||
| NPI: | 1083236947 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POUDRE VALLEY MEDICAL GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2695 ROCKY MOUNTAIN AVE STE 150 | ||||||||
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| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805389071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1936519507 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4190 E WOODMEN RD STE 100 | ||||||||
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| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809208075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193651950 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2020 | ||||||||
| LastUpdateDate: | 05/14/2020 | ||||||||
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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: | 05/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.