Provider Demographics
NPI:1205187325
Name:CENTERVILLE MEDICAL CENTER
Entity Type:Organization
Organization Name:CENTERVILLE MEDICAL CENTER
Other - Org Name:MAPLEWOOD MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-298-7330
Mailing Address - Street 1:6783 S REDWOOD RD STE 104
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-5686
Mailing Address - Country:US
Mailing Address - Phone:801-298-7330
Mailing Address - Fax:801-295-5434
Practice Address - Street 1:6783 S REDWOOD RD
Practice Address - Street 2:SUITE 104
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-5677
Practice Address - Country:US
Practice Address - Phone:801-268-2929
Practice Address - Fax:801-268-0198
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTERVILLE MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-28
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000067114Medicare PIN