Provider Demographics
NPI:1114152527
Name:BLUE MOUNTAIN HOSPITAL
Entity Type:Organization
Organization Name:BLUE MOUNTAIN HOSPITAL
Other - Org Name:DIALYSIS UNIT
Other - Org Type:Other Name
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
Mailing Address - Country:US
Mailing Address - Phone:435-678-3993
Mailing Address - Fax:435-678-3992
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
Practice Address - Country:US
Practice Address - Phone:435-678-3993
Practice Address - Fax:435-678-3992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-29
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QE0700X
UT2012-ESRD-90350261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT462319Medicare Oscar/Certification