Provider Demographics
NPI:1790273704
Name:THE ADDICTION MEDICINE PHYSICIANS GROUP, LLC
Entity Type:Organization
Organization Name:THE ADDICTION MEDICINE PHYSICIANS GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRELL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SELLERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-859-8092
Mailing Address - Street 1:9160 S. 300 E STE 25
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070
Mailing Address - Country:US
Mailing Address - Phone:801-859-8092
Mailing Address - Fax:844-965-9279
Practice Address - Street 1:9160 S 300 E. STE 25
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070
Practice Address - Country:US
Practice Address - Phone:801-859-8092
Practice Address - Fax:844-965-9279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT311613-3102163WA0400X
UT293281-1205207LA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction MedicineGroup - Multi-Specialty
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)Group - Multi-Specialty