Provider Demographics
NPI:1538708854
Name:INTERMOUNTAIN MEDICAL GROUP GRAND JUNCTION, LLC
Entity type:Organization
Organization Name:INTERMOUNTAIN MEDICAL GROUP GRAND JUNCTION, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP FINANCE MEDICAL GROUP
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 1:710 WELLINGTON AVE
Mailing Address - Street 2:ENTRANCE 20
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-6123
Mailing Address - Country:US
Mailing Address - Phone:970-298-6601
Mailing Address - Fax:970-298-6641
Practice Address - Street 1:710 WELLINGTON AVE
Practice Address - Street 2:ENTRANCE 20
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-6123
Practice Address - Country:US
Practice Address - Phone:970-298-6601
Practice Address - Fax:970-298-6641
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTERMOUNTAIN FRONT RANGE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-01-03
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty