Provider Demographics
NPI:1083654016
Name:MMPS OGDEN
Entity Type:Organization
Organization Name:MMPS OGDEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PENROD
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:801-284-1705
Mailing Address - Street 1:1485 E SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-4837
Mailing Address - Country:US
Mailing Address - Phone:801-475-4552
Mailing Address - Fax:801-475-4578
Practice Address - Street 1:1485 E SKYLINE DR
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-4837
Practice Address - Country:US
Practice Address - Phone:801-475-4552
Practice Address - Fax:801-475-4578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5032435-0160261QM1300X, 261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000055427Medicare ID - Type Unspecified
UT=========009Medicaid