Provider Demographics
NPI:1740216860
Name:ALPINE MEDICAL GROUP
Entity Type:Organization
Organization Name:ALPINE MEDICAL GROUP
Other - Org Name:ALPINE INTERNAL MEDICINE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:
Authorized Official - Last Name:MEZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-328-1260
Mailing Address - Street 1:24 S 1100 E STE 310
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1500
Mailing Address - Country:US
Mailing Address - Phone:801-328-1260
Mailing Address - Fax:801-350-4361
Practice Address - Street 1:24 S 1100 E STE 310
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1500
Practice Address - Country:US
Practice Address - Phone:801-328-1260
Practice Address - Fax:801-350-4361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000055479Medicare PIN