Provider Demographics
NPI:1710643549
Name:GOOD SHEPHERD MEDICAL GROUP
Entity Type:Organization
Organization Name:GOOD SHEPHERD MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:NATHANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEFEVOR
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:801-574-9566
Mailing Address - Street 1:3584 W 9000 S STE 300
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-5711
Mailing Address - Country:US
Mailing Address - Phone:801-277-6474
Mailing Address - Fax:877-789-0498
Practice Address - Street 1:3584 W 9000 S STE 300
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-5711
Practice Address - Country:US
Practice Address - Phone:801-277-6474
Practice Address - Fax:877-789-0498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty