Basic Information
Provider Information | |||||||||
NPI: | 1992335061 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | POUDRE VALLEY MEDICAL GROUP, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2695 ROCKY MOUNTAIN AVE STE 150 | ||||||||
Address2: |   | ||||||||
City: | LOVELAND | ||||||||
State: | CO | ||||||||
PostalCode: | 805389071 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9706244443 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1500 S LEMAY AVE | ||||||||
Address2: |   | ||||||||
City: | FORT COLLINS | ||||||||
State: | CO | ||||||||
PostalCode: | 805244262 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9704958780 | ||||||||
FaxNumber: | 9704958799 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/17/2020 | ||||||||
LastUpdateDate: | 01/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CONROY | ||||||||
AuthorizedOfficialFirstName: | JANA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER CREDENTIALING | ||||||||
AuthorizedOfficialTelephone: | 9706244443 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | RHIA | ||||||||
NPICertificationDate: | 01/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
No ID Information.