Provider Demographics
NPI:1942317722
Name:GREEN RIVER MEDICAL CENTER INC
Entity Type:Organization
Organization Name:GREEN RIVER MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:B
Authorized Official - Last Name:WINTERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-564-3434
Mailing Address - Street 1:585 WEST MAIN ST.
Mailing Address - Street 2:BOX 417
Mailing Address - City:GREEN RIVER
Mailing Address - State:UT
Mailing Address - Zip Code:84525-0417
Mailing Address - Country:US
Mailing Address - Phone:435-564-3434
Mailing Address - Fax:435-564-3214
Practice Address - Street 1:585 WEST MAIN ST.
Practice Address - Street 2:BOX 417
Practice Address - City:GREEN RIVER
Practice Address - State:UT
Practice Address - Zip Code:84525-0417
Practice Address - Country:US
Practice Address - Phone:435-564-3434
Practice Address - Fax:435-564-3214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT572622038001Medicaid
UT=========011Medicaid
UT=========008Medicaid
UT=========011Medicaid