Provider Demographics
NPI:1558391763
Name:MOUNTAIN WEST ANESTHESIA LLC
Entity Type:Organization
Organization Name:MOUNTAIN WEST ANESTHESIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BILLING AND COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:TACY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-990-1910
Mailing Address - Street 1:PO BOX 3570
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-3570
Mailing Address - Country:US
Mailing Address - Phone:800-501-4788
Mailing Address - Fax:801-432-2669
Practice Address - Street 1:3340 N CENTER ST
Practice Address - Street 2:SUITE 800
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-7406
Practice Address - Country:US
Practice Address - Phone:801-990-1911
Practice Address - Fax:801-990-1912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========005Medicaid
UT000055327Medicare PIN