Provider Demographics
NPI:1619282571
Name:UTAH PHS LLC
Entity Type:Organization
Organization Name:UTAH PHS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-261-4843
Mailing Address - Street 1:9155 CRESTWYN HILLS DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125-8501
Mailing Address - Country:US
Mailing Address - Phone:901-261-4848
Mailing Address - Fax:901-261-4849
Practice Address - Street 1:321 N MALL DR BLDG R
Practice Address - Street 2:RED CLIFFS PROFESSIONAL PARK
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-7302
Practice Address - Country:US
Practice Address - Phone:877-260-4747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-16
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAU000072523Medicare PIN