Provider Demographics
NPI:1013121003
Name:ALPINE PLASTIC AND RECONSTRUCTIVE SURGERY, LLC
Entity Type:Organization
Organization Name:ALPINE PLASTIC AND RECONSTRUCTIVE SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLE
Authorized Official - Middle Name:T
Authorized Official - Last Name:GROBE
Authorized Official - Suffix:
Authorized Official - Credentials:CCS-P, CPC
Authorized Official - Phone:801-689-3506
Mailing Address - Street 1:5405 S 500 E
Mailing Address - Street 2:SUITE101
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-6957
Mailing Address - Country:US
Mailing Address - Phone:801-689-3500
Mailing Address - Fax:801-689-3505
Practice Address - Street 1:5405 S 500 E
Practice Address - Street 2:SUITE101
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6957
Practice Address - Country:US
Practice Address - Phone:801-689-3500
Practice Address - Fax:801-689-3505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000055634Medicare PIN