Provider Demographics
NPI:1003825134
Name:ALPINE MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:ALPINE MEDICAL GROUP, LLC
Other - Org Name:ALPINE NEUROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-364-1117
Mailing Address - Street 1:1002 E SOUTH TEMPLE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1525
Mailing Address - Country:US
Mailing Address - Phone:801-364-1117
Mailing Address - Fax:801-364-1124
Practice Address - Street 1:1002 E S TEMPLE
Practice Address - Street 2:SUITE 207
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102
Practice Address - Country:US
Practice Address - Phone:801-364-1117
Practice Address - Fax:801-364-1124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000055478Medicare ID - Type Unspecified
UT000055478Medicare PIN