Basic Information
| Provider Information | |||||||||
| NPI: | 1265638357 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNTAINSTAR SPECIALTY SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 HEALTH PARK DR | ||||||||
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| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153737600 | ||||||||
| FaxNumber: | 8663461426 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 E 3900 S | ||||||||
| Address2: | STE 460 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841241348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012623564 | ||||||||
| FaxNumber: | 8012623613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2007 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
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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: | 10/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1265638357 | 05 | UT | MEDICAID |