Provider Demographics
NPI:1922142546
Name:ALPINE DERMATOLOGY PC
Entity Type:Organization
Organization Name:ALPINE DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHERYL LEE
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:EBERTING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-763-7107
Mailing Address - Street 1:144 S MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ALPINE
Mailing Address - State:UT
Mailing Address - Zip Code:84004-1666
Mailing Address - Country:US
Mailing Address - Phone:801-763-7107
Mailing Address - Fax:801-763-7106
Practice Address - Street 1:144 S MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:ALPINE
Practice Address - State:UT
Practice Address - Zip Code:84004-1666
Practice Address - Country:US
Practice Address - Phone:801-763-7107
Practice Address - Fax:801-763-7106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT62699311205207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty