Basic Information
| Provider Information | |||||||||
| NPI: | 1538633698 | ||||||||
| 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: | 9706244443 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1035 GARDEN OF THE GODS RD STE 120 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809073416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193291000 | ||||||||
| FaxNumber: | 7195980807 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2019 | ||||||||
| 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: | RHIA | ||||||||
| NPICertificationDate: | 01/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 2083X0100X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine |
ID Information
| ID | Type | State | Issuer | Description | 68135076 | 05 | CO | MEDICAID |