Provider Demographics
NPI:1720035520
Name:MOUNTAIN MEDICAL PHYSICIAN SPECIALISTS PC
Entity Type:Organization
Organization Name:MOUNTAIN MEDICAL PHYSICIAN SPECIALISTS PC
Other - Org Name:UTAH RADIOLOGY ASSOCIATES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PENROD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-284-1705
Mailing Address - Street 1:5334 S WOODROW ST STE 101
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5838
Mailing Address - Country:US
Mailing Address - Phone:801-284-1755
Mailing Address - Fax:
Practice Address - Street 1:5334 S WOODROW ST STE 101
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5838
Practice Address - Country:US
Practice Address - Phone:801-284-1755
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1328836-01442085B0100X, 2085N0700X, 2085R0202X, 2085R0204X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========009Medicaid
UT=========009Medicaid