Provider Demographics
NPI:1871330100
Name:INTERMOUNTAIN MEDICAL GROUP DENVER, LLC
Entity type:Organization
Organization Name:INTERMOUNTAIN MEDICAL GROUP DENVER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-272-0231
Mailing Address - Street 1:500 ELDORADO BLVD STE 4300
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80021-3564
Mailing Address - Country:US
Mailing Address - Phone:303-272-0566
Mailing Address - Fax:303-272-0390
Practice Address - Street 1:12905 W 40TH AVE, STE 420
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80401
Practice Address - Country:US
Practice Address - Phone:303-265-5670
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTERMOUNTAIN FRONT RANGE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-07-12
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Multi-Specialty