Provider Demographics
NPI:1467974311
Name:OUTREACH MEDICAL GROUP
Entity Type:Organization
Organization Name:OUTREACH MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:STELTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-644-5121
Mailing Address - Street 1:3385 W 2525 N
Mailing Address - Street 2:
Mailing Address - City:PLAIN CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84404-9228
Mailing Address - Country:US
Mailing Address - Phone:801-644-5121
Mailing Address - Fax:
Practice Address - Street 1:3385 W 2525 N
Practice Address - Street 2:
Practice Address - City:PLAIN CITY
Practice Address - State:UT
Practice Address - Zip Code:84404-9228
Practice Address - Country:US
Practice Address - Phone:801-644-5121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-12
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT309877-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT309877-1205OtherLICENSE