Provider Demographics
NPI:1639350705
Name:MOUNTAINSTAR CARDIOVASCULAR SERVICES LLC
Entity Type:Organization
Organization Name:MOUNTAINSTAR CARDIOVASCULAR SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KIRT
Authorized Official - Middle Name:L
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-743-4750
Mailing Address - Street 1:425 E 5350 S
Mailing Address - Street 2:SUITE #350
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-6946
Mailing Address - Country:US
Mailing Address - Phone:801-476-6900
Mailing Address - Fax:801-476-6991
Practice Address - Street 1:425 E 5350 S
Practice Address - Street 2:SUITE #350
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6946
Practice Address - Country:US
Practice Address - Phone:801-476-6900
Practice Address - Fax:801-476-6991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty