Provider Demographics
NPI:1316316482
Name:NORTHEASTERN UTAH MEDICAL GROUP
Entity type:Organization
Organization Name:NORTHEASTERN UTAH MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:I
Authorized Official - Last Name:MARSHAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-722-6162
Mailing Address - Street 1:250 W 300 N
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066-2336
Mailing Address - Country:US
Mailing Address - Phone:435-722-4691
Mailing Address - Fax:435-722-9291
Practice Address - Street 1:250 W 300 N
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066-2336
Practice Address - Country:US
Practice Address - Phone:435-722-4691
Practice Address - Fax:435-722-9291
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UINTAH BASIN MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-18
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6411766-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty