Provider Demographics
NPI:1316160534
Name:EVERGREEN MEDICAL, INC.
Entity type:Organization
Organization Name:EVERGREEN MEDICAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARCI
Authorized Official - Middle Name:A
Authorized Official - Last Name:MERRILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-676-7627
Mailing Address - Street 1:PO BOX 900280
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84090-0280
Mailing Address - Country:US
Mailing Address - Phone:801-676-7627
Mailing Address - Fax:801-676-7629
Practice Address - Street 1:96 E KIMBALLS LN STE 304
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-5021
Practice Address - Country:US
Practice Address - Phone:801-676-7627
Practice Address - Fax:801-676-7629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1750351847OtherDR NPI
UT1649377540OtherDR NPI
UT1285604462OtherDR NPI
MA1013980119OtherDR NPI