1659236990 NPI number — POUDRE VALLEY MEDICAL GROUP, LLC

Table of content: MS. TAMMARA O'NEIL TRAIL CAC, CCGC (NPI 1649543638)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659236990 NPI number — POUDRE VALLEY MEDICAL GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POUDRE VALLEY MEDICAL GROUP, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659236990
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2695 ROCKY MOUNTAIN AVE STE 150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOVELAND
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80538-9071
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9051 SSG CHRIS FALKEL DRIVE
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
HIGHLANDS RANCH
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80129-3190
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-213-4507
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/18/2025

Additional Information

Authorized Official

Authorized Official Last Name:
CONROY
Authorized Official First Name:
JANA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF CREDENTIALING
Authorized Official Telephone Number:
720-213-4507

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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