Provider Demographics
NPI:1245267467
Name:HTI PHYSICAN SERVICES OF UTAH,INC
Entity type:Organization
Organization Name:HTI PHYSICAN SERVICES OF UTAH,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-455-3718
Mailing Address - Street 1:1717 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4802
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:124 5TH STREET
Practice Address - Street 2:SUITE A
Practice Address - City:WILDER
Practice Address - State:ID
Practice Address - Zip Code:83676-0037
Practice Address - Country:US
Practice Address - Phone:208-482-7430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST VALLEY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-26
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1245267467Medicaid
ID1245267467Medicaid