Provider Demographics
NPI:1265638357
Name:MOUNTAINSTAR SPECIALTY SERVICES LLC
Entity Type:Organization
Organization Name:MOUNTAINSTAR SPECIALTY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-373-7630
Mailing Address - Street 1:2000 HEALTH PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4525
Mailing Address - Country:US
Mailing Address - Phone:615-373-7406
Mailing Address - Fax:866-346-1426
Practice Address - Street 1:1250 E 3900 S
Practice Address - Street 2:STE 460
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1348
Practice Address - Country:US
Practice Address - Phone:801-262-3564
Practice Address - Fax:801-262-3613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1265638357Medicaid
UT1265638357Medicaid
UT000061276Medicare PIN