Provider Demographics
NPI:1639793367
Name:NORTHWEST GERIACTRICS
Entity Type:Organization
Organization Name:NORTHWEST GERIACTRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:MBA/MHA
Authorized Official - Phone:435-862-6143
Mailing Address - Street 1:206 N 2100 W STE 202
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-4741
Mailing Address - Country:US
Mailing Address - Phone:435-862-6143
Mailing Address - Fax:
Practice Address - Street 1:10365 SE SUNNYSIDE RD STE 340
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-5751
Practice Address - Country:US
Practice Address - Phone:143-586-2614
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-28
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty