Provider Demographics
NPI:1215010327
Name:HIGHLAND MEDICAL PLLC
Entity Type:Organization
Organization Name:HIGHLAND MEDICAL PLLC
Other - Org Name:HIGHLAND FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MUSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-272-4111
Mailing Address - Street 1:4460 SO HIGHLAND DR
Mailing Address - Street 2:#400
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124
Mailing Address - Country:US
Mailing Address - Phone:801-272-4111
Mailing Address - Fax:801-272-5989
Practice Address - Street 1:4460 HIGHLAND DR
Practice Address - Street 2:STE 400
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-3565
Practice Address - Country:US
Practice Address - Phone:801-272-4111
Practice Address - Fax:801-272-5989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1813021205207Q00000X, 305R00000X
UT3484061205207Q00000X
UT3655121205207Q00000X
UT2763721206207Q00000X
UT2879974405207Q00000X
UT1045691206207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528940093006Medicaid
UT528940093006Medicaid
UTD44309Medicare UPIN