Provider Demographics
NPI:1194446492
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 FIANCE
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 1:2643 PATTERSON RD STE 405
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-1937
Practice Address - Country:US
Practice Address - Phone:970-298-5920
Practice Address - Fax:970-372-1710
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTERMOUNTAIN FRONT RANGE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-09-06
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty