Provider Demographics
NPI:1073795258
Name:MOUNTAINSTAR MEDICAL GROUP-ST. MARKS HOSPITAL, LLC
Entity Type:Organization
Organization Name:MOUNTAINSTAR MEDICAL GROUP-ST. MARKS HOSPITAL, LLC
Other - Org Name:ST. MARK'S MILLCREEK PRIMARY CARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-373-7630
Mailing Address - Street 1:2000 HEALTH PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4525
Mailing Address - Country:US
Mailing Address - Phone:615-373-7600
Mailing Address - Fax:866-346-1426
Practice Address - Street 1:348 E 4500 S STE 300
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-8535
Practice Address - Country:US
Practice Address - Phone:801-266-2777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1073795258Medicaid
UT000062330Medicare PIN