Provider Demographics
NPI:1083622641
Name:LONE PEAK ANESTHESIA LC
Entity Type:Organization
Organization Name:LONE PEAK ANESTHESIA LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:J. TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:NILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-594-5736
Mailing Address - Street 1:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-3810
Mailing Address - Country:US
Mailing Address - Phone:800-594-5736
Mailing Address - Fax:678-285-6777
Practice Address - Street 1:150 W CIVIC CENTER DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-4230
Practice Address - Country:US
Practice Address - Phone:801-432-2677
Practice Address - Fax:678-285-6777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid
UT000055891Medicare PIN
UTCJ6265Medicare PIN