Provider Demographics
NPI:1033538731
Name:BLUE MOUNTAIN HOSPITAL DIALYSIS
Entity Type:Organization
Organization Name:BLUE MOUNTAIN HOSPITAL DIALYSIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:LYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:435-678-3993
Mailing Address - Street 1:802 S 200 W
Mailing Address - Street 2:SUITE A
Mailing Address - City:BLANDING
Mailing Address - State:UT
Mailing Address - Zip Code:84511-3910
Mailing Address - Country:US
Mailing Address - Phone:435-678-3993
Mailing Address - Fax:
Practice Address - Street 1:802 S 200 W
Practice Address - Street 2:SUITE A
Practice Address - City:BLANDING
Practice Address - State:UT
Practice Address - Zip Code:84511-3910
Practice Address - Country:US
Practice Address - Phone:435-678-3993
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLUE MOUNTAIN HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-09
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2012-ESRD-90350282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1114152527Medicare Oscar/Certification