Basic Information
| Provider Information | |||||||||
| NPI: | 1144475674 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNTAINSTAR MEDICAL GROUP- CACHE VALLEY, LLC | ||||||||
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| OtherOrganizationName: | MOUNTAINSTAR CACHE VALLEY MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 HEALTH PARK DR | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153737600 | ||||||||
| FaxNumber: | 8663461426 | ||||||||
| Practice Location | |||||||||
| Address1: | 382 W 280 N | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843329753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357520330 | ||||||||
| FaxNumber: | 4357550922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2008 | ||||||||
| LastUpdateDate: | 10/28/2020 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | TEDRICK | ||||||||
| AuthorizedOfficialTitleorPosition: | GROUP VP/AO | ||||||||
| AuthorizedOfficialTelephone: | 6153723375 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1144475674 | 05 | UT | MEDICAID |