Provider Demographics
NPI:1770247470
Name:OLYMPUS MEDICAL
Entity type:Organization
Organization Name:OLYMPUS MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-632-6877
Mailing Address - Street 1:279 SUNRISE DR
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:UT
Mailing Address - Zip Code:84004-1563
Mailing Address - Country:US
Mailing Address - Phone:801-430-0282
Mailing Address - Fax:
Practice Address - Street 1:279 SUNRISE DR
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:UT
Practice Address - Zip Code:84004-1563
Practice Address - Country:US
Practice Address - Phone:801-430-0282
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical NeurophysiologyGroup - Multi-Specialty