Provider Demographics
NPI:1306030440
Name:ALPINE MEDICAL GROUP
Entity type:Organization
Organization Name:ALPINE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIXIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-478-0010
Mailing Address - Street 1:24 S 1100 E
Mailing Address - Street 2:201
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1500
Mailing Address - Country:US
Mailing Address - Phone:801-478-0010
Mailing Address - Fax:
Practice Address - Street 1:24 S 1100 E
Practice Address - Street 2:201
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1500
Practice Address - Country:US
Practice Address - Phone:801-478-0010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALPINE MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-31
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000058025Medicare PIN