Provider Demographics
NPI:1982871828
Name:ST. MARK'S SOUTH JORDAN FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:ST. MARK'S SOUTH JORDAN FAMILY PRACTICE LLC
Other - Org Name:SOUTH JORDAN FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:KANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-568-5999
Mailing Address - Street 1:10623 S REDWOOD RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-2481
Mailing Address - Country:US
Mailing Address - Phone:801-302-0899
Mailing Address - Fax:801-302-0892
Practice Address - Street 1:10623 S REDWOOD RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-2481
Practice Address - Country:US
Practice Address - Phone:801-302-0899
Practice Address - Fax:801-302-0892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-09
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1982871828Medicaid
DN6477Medicare PIN
UT000063824Medicare PIN