Provider Demographics
NPI:1730533902
Name:INTERMOUNTAIN MEDICAL GROUP DENVER, LLC
Entity type:Organization
Organization Name:INTERMOUNTAIN MEDICAL GROUP DENVER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP FINANCE - MGPS OPERATIONS
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 1:9351 GRANT ST
Mailing Address - Street 2:STE 490
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80229-4358
Mailing Address - Country:US
Mailing Address - Phone:303-451-5271
Mailing Address - Fax:303-452-4398
Practice Address - Street 1:9351 GRANT ST
Practice Address - Street 2:STE 490
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80229-4358
Practice Address - Country:US
Practice Address - Phone:303-451-5271
Practice Address - Fax:303-452-4398
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTERMOUNTAIN FRONT RANGE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-14
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPOD.0000520213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty