Provider Demographics
NPI:1922280007
Name:UINTAH BASIN MEDICAL CENTER
Entity Type:Organization
Organization Name:UINTAH BASIN MEDICAL CENTER
Other - Org Name:UINTAH BASIN MEDICAL CENTER DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:FACHE
Authorized Official - Phone:435-722-6162
Mailing Address - Street 1:250 W 300 N
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066-2336
Mailing Address - Country:US
Mailing Address - Phone:435-722-4691
Mailing Address - Fax:435-722-9291
Practice Address - Street 1:250 W 300 N
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066-2336
Practice Address - Country:US
Practice Address - Phone:435-722-4691
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2007-ESRD-82816261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT463505Medicare Oscar/Certification