Provider Demographics
NPI:1639546377
Name:ADVANCED FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:ADVANCED FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:A
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-656-0234
Mailing Address - Street 1:619 S BLUFF ST
Mailing Address - Street 2:TOWER 1 SUITE 100
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-3853
Mailing Address - Country:US
Mailing Address - Phone:435-656-0234
Mailing Address - Fax:435-656-2622
Practice Address - Street 1:619 S BLUFF ST
Practice Address - Street 2:TOWER 1 SUITE 100
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-3853
Practice Address - Country:US
Practice Address - Phone:435-656-0234
Practice Address - Fax:435-656-2622
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED FAMILY MEDICINE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-08-28
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty