Basic Information
| Provider Information | |||||||||
| NPI: | 1215332762 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | POUDRE VALLEY HEALTH CARE INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | POUDRE VALLEY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7901 E LOWRY BLVD | ||||||||
| Address2: | F402, 3RD FLOOR | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802306507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7205531700 | ||||||||
| FaxNumber: | 7205531754 | ||||||||
| Practice Location | |||||||||
| Address1: | 4601 CORBETT DR | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805289579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702074800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2014 | ||||||||
| LastUpdateDate: | 01/03/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RIEBER | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | DANIEL | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7208487836 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | POUDRE VALLEY HEALTH CARE INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | CO | N | Hospital Units | Psychiatric Unit | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 00025PO | 01 | CO | BLUE CROSS COLORADO | OTHER | 6160355 | 01 | CO | AMERICA'S HEALTH PLAN | OTHER | 75276 | 01 | CO | WORLD INSURANCE | OTHER | 86373251 | 01 | CO | MEDICAID RTCF | OTHER | H188 | 01 | CO | MIDLANDS CHOICE | OTHER | 44054 | 01 | CO | GOV EMPLOYEE HOSPITAL ASSOCIATION | OTHER | 05010004 | 05 | CO | MEDICAID | 618515 | 01 | CO | STATE FARM | OTHER | B001 | 01 | CO | TRICARE WPS | OTHER | 06060123 | 05 | CO | MEDICAID | 81933762 | 05 | CO | MEDICAID | DE0901 | 01 | CO | RAILROAD MEDICARE | OTHER | 0694280 | 01 | CO | AETNA | OTHER | 1192523-00 | 05 | WY | MEDICAID | D8004 | 01 | CO | MEDICARE PART B | OTHER |