Provider Demographics
NPI:1578859831
Name:MOUNTAINSTAR MEDICAL GROUP NEUROSURGERY - ST MARKS LLC
Entity Type:Organization
Organization Name:MOUNTAINSTAR MEDICAL GROUP NEUROSURGERY - ST MARKS 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 1:1220 E 3900 S
Practice Address - Street 2:STE. 4-E
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1377
Practice Address - Country:US
Practice Address - Phone:801-261-8507
Practice Address - Fax:801-261-8507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-24
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty