Provider Demographics
NPI:1558513812
Name:BLUE MOUNTAIN HOSPITAL
Entity Type:Organization
Organization Name:BLUE MOUNTAIN HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:LYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:435-678-3993
Mailing Address - Street 1:802 S 200 WEST
Mailing Address - Street 2:SUITE A
Mailing Address - City:BLANDING
Mailing Address - State:UT
Mailing Address - Zip Code:84511
Mailing Address - Country:US
Mailing Address - Phone:435-678-3993
Mailing Address - Fax:435-678-3992
Practice Address - Street 1:802 S 200 WEST
Practice Address - Street 2:SUITE A
Practice Address - City:BLANDING
Practice Address - State:UT
Practice Address - Zip Code:84511
Practice Address - Country:US
Practice Address - Phone:435-678-3993
Practice Address - Fax:435-678-3992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-17
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2011-HOSP-96389261QC0050X
UT2010-ESRD-90350261QE0700X
UT275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC0050XAmbulatory Health Care FacilitiesClinic/CenterCritical Access Hospital
No261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
No275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ452579Medicaid
UT1558513812Medicaid
UT462319Medicare Oscar/Certification
AZ452579Medicaid
UT46Z310Medicare Oscar/Certification
UT000065473Medicare UPIN
UT46-Z310Medicare UPIN
UT461310Medicare Oscar/Certification