1396358578 NPI number — INTERMOUNTAIN MEDICAL GROUP GRAND JUNCTION, LLC

Table of content: (NPI 1396358578)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396358578 NPI number — INTERMOUNTAIN MEDICAL GROUP GRAND JUNCTION, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERMOUNTAIN MEDICAL GROUP GRAND JUNCTION, 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:
6
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:
1396358578
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
350 MARKET ST UNIT 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BASALT
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81621-7410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-927-1141
Provider Business Mailing Address Fax Number:
866-941-5664

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 MARKET ST UNIT 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BASALT
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81621-7410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-927-1141
Provider Business Practice Location Address Fax Number:
866-941-5664
Provider Enumeration Date:
08/26/2020

Additional Information

Authorized Official

Authorized Official Last Name:
MCDANIEL
Authorized Official First Name:
JON
Authorized Official Middle Name:
Authorized Official Title or Position:
VP FINANCE MEDICAL GROUP
Authorized Official Telephone Number:
303-272-0231

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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