Provider Demographics
NPI:1255691929
Name:SOUTH PAYSON MEDICAL CLINIC
Entity Type:Organization
Organization Name:SOUTH PAYSON MEDICAL CLINIC
Other - Org Name:SOUTH PAYSON CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:MEREDITH
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:940-634-1977
Mailing Address - Street 1:828 S 1040 W
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:UT
Mailing Address - Zip Code:84651-4614
Mailing Address - Country:US
Mailing Address - Phone:940-634-1977
Mailing Address - Fax:
Practice Address - Street 1:828 S 1040 W
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-4614
Practice Address - Country:US
Practice Address - Phone:940-634-1977
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-29
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2785828-1206261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center