Provider Demographics
NPI:1740482009
Name:NORTHEASTERN UTAH MEDICAL GROUP
Entity type:Organization
Organization Name:NORTHEASTERN UTAH MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:K
Authorized Official - Last Name:MARETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-722-6270
Mailing Address - Street 1:210 W 300 N 75 3
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066
Mailing Address - Country:US
Mailing Address - Phone:435-722-3971
Mailing Address - Fax:435-722-6104
Practice Address - Street 1:210 W 300 N 75 3
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066
Practice Address - Country:US
Practice Address - Phone:435-722-3971
Practice Address - Fax:435-722-6104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========000Medicaid
UT1068670001Medicare NSC