Provider Demographics
NPI:1265694509
Name:MOUNTAINSTAR OGDEN PEDIATRICS LLC
Entity type:Organization
Organization Name:MOUNTAINSTAR OGDEN PEDIATRICS LLC
Other - Org Name:
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:37027-4525
Mailing Address - Country:US
Mailing Address - Phone:615-373-7406
Mailing Address - Fax:866-346-1426
Practice Address - Street 1:5495 S 500 E
Practice Address - Street 2:SUITE 120
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6923
Practice Address - Country:US
Practice Address - Phone:801-479-0174
Practice Address - Fax:801-479-8888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-27
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1265694509Medicaid