Provider Demographics
NPI:1194860569
Name:HUNTER MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:HUNTER MEDICAL CENTER, INC
Other - Org Name:JORDAN MEADOWS MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:M
Authorized Official - Last Name:CIVISH
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:801-969-6264
Mailing Address - Street 1:3534 S 6000 W
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY
Mailing Address - State:UT
Mailing Address - Zip Code:84128-2610
Mailing Address - Country:US
Mailing Address - Phone:801-969-6264
Mailing Address - Fax:801-969-6333
Practice Address - Street 1:3534 S 6000 W
Practice Address - Street 2:
Practice Address - City:WEST VALLEY
Practice Address - State:UT
Practice Address - Zip Code:84128-2610
Practice Address - Country:US
Practice Address - Phone:801-969-6264
Practice Address - Fax:801-969-6333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT184916-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTE15068Medicare UPIN