Provider Demographics
NPI:1154304749
Name:RIDGELINE ENDOSCOPY CENTER L.C.
Entity type:Organization
Organization Name:RIDGELINE ENDOSCOPY CENTER L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LOWE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-475-5400
Mailing Address - Street 1:6028 S RIDGELINE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-6914
Mailing Address - Country:US
Mailing Address - Phone:801-475-4988
Mailing Address - Fax:801-475-4948
Practice Address - Street 1:6028 S RIDGELINE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6914
Practice Address - Country:US
Practice Address - Phone:801-475-4988
Practice Address - Fax:801-475-4948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2004-ASF-9993261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT876047546005Medicaid
49004666OtherRAILROAD MEDICARE