Provider Demographics
NPI:1134379696
Name:MOUNTAINSTAR BRIGHAM OBGYN, LLC
Entity type:Organization
Organization Name:MOUNTAINSTAR BRIGHAM OBGYN, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-373-7630
Mailing Address - Street 1:2000 HEALTH PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4692
Mailing Address - Country:US
Mailing Address - Phone:615-373-7406
Mailing Address - Fax:
Practice Address - Street 1:970 MEDICAL DR STE 202
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-3286
Practice Address - Country:US
Practice Address - Phone:435-695-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-22
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1134379696Medicaid
UT000065084Medicare PIN
UT1134379696Medicaid