Provider Demographics
NPI:1932640752
Name:INDIEMED LLC
Entity Type:Organization
Organization Name:INDIEMED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:435-635-1148
Mailing Address - Street 1:25 N 2000 W STE 3
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:UT
Mailing Address - Zip Code:84737-4115
Mailing Address - Country:US
Mailing Address - Phone:435-635-1148
Mailing Address - Fax:435-635-1146
Practice Address - Street 1:25 N 2000 W STE 3
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:UT
Practice Address - Zip Code:84737-4115
Practice Address - Country:US
Practice Address - Phone:435-635-1148
Practice Address - Fax:435-635-1146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7443632-1206261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care