Provider Demographics
NPI:1972078723
Name:PHYSICIAN MEDICAL GROUP
Entity type:Organization
Organization Name:PHYSICIAN MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMBARI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:385-800-5015
Mailing Address - Street 1:4624 S HOLLADAY BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-7168
Mailing Address - Country:US
Mailing Address - Phone:801-810-2999
Mailing Address - Fax:801-407-0747
Practice Address - Street 1:4624 S HOLLADAY BLVD STE 202
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-7168
Practice Address - Country:US
Practice Address - Phone:385-800-5015
Practice Address - Fax:801-277-6678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-08
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1740543834OtherINDIVIDUAL NPI
UT1619935053OtherINDIVIDUAL NPI
UT1184807208OtherINDIVIDUAL NPI
UT1356897821OtherINDIVIDUAL NPI
UT1861622219OtherINDIVIDUAL NPI
UT1972078723OtherGROUP NPI