Provider Demographics
NPI:1457325573
Name:ST GEORGE ENDOSCOPY CENTER LLC
Entity Type:Organization
Organization Name:ST GEORGE ENDOSCOPY CENTER LLC
Other - Org Name:ST. GEORGE ENDOSCOPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SNODGRASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:368 E RIVERSIDE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-6896
Mailing Address - Country:US
Mailing Address - Phone:435-674-3109
Mailing Address - Fax:435-674-3505
Practice Address - Street 1:368 E RIVERSIDE DR
Practice Address - Street 2:SUITE B
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-6896
Practice Address - Country:US
Practice Address - Phone:435-674-3109
Practice Address - Fax:435-674-3505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2004-ASF-49065261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid
UT000100079Medicare PIN
UTP00052658Medicare PIN
UT46C0001035Medicare Oscar/Certification