Provider Demographics
NPI:1578869954
Name:DIRECTMD, LLC
Entity Type:Organization
Organization Name:DIRECTMD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MACKELPRANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-870-8500
Mailing Address - Street 1:PO BOX 671
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84025-0671
Mailing Address - Country:US
Mailing Address - Phone:801-870-8500
Mailing Address - Fax:801-939-9998
Practice Address - Street 1:SALT LAKE COUNTY GOVERNMENT CTR
Practice Address - Street 2:2001 SOUTH STATE STREET, STE S2400
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84190-0001
Practice Address - Country:US
Practice Address - Phone:801-870-8500
Practice Address - Fax:801-467-8393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center