1053597237 NPI number — MOUNTAIN MEDICAL PHYSICIAN SPECIALISTS OF IDAHO PC

Table of content: MARY E ELLISON OPTICIAN (NPI 1265603385)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053597237 NPI number — MOUNTAIN MEDICAL PHYSICIAN SPECIALISTS OF IDAHO PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNTAIN MEDICAL PHYSICIAN SPECIALISTS OF IDAHO PC
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:
1053597237
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5444 GREEN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MURRAY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84123-5632
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-284-1755
Provider Business Mailing Address Fax Number:
801-262-3897

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1501 HILAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83318-2682
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-284-1755
Provider Business Practice Location Address Fax Number:
801-262-3897
Provider Enumeration Date:
01/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
CLARK
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
801-284-1705

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  C176456 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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