MEDICARE: BLUE SAGE MEDICAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP2300X	Primary Care Nurse Practitioner	123071-4405	UT

General Provider Information

NPI Number	:	1487016226
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE SAGE MEDICAL LLC

Provider Business Mailing Address
First Line	:	6300 SAGEWOOD DR
Second Line	:	SUITE H-532
City	:	PARK CITY
State	:	UT
Zip	:	84098-7502
Country	:	US
Telephone Number	:	801-718-7280
Fax Number	:	888-853-5162

Provider Business Practice Location Address
First Line	:	6300 SAGEWOOD DR
Second Line	:	SUITE H-532
City	:	PARK CITY
State	:	UT
Zip	:	84098-7502
Country	:	US
Telephone Number	:	801-718-7280
Fax Number	:	888-853-5162

Authorized Official
Title or Position	:	AGPCNP
Name	:	GINA COCCIMIGLIO
Credential	:	NP
Telephone Number	:	801-718-7280

Provider Enumeration Date	:	03/22/2016
Last Update Date	:	08/29/2017

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Directions to “BLUE SAGE MEDICAL LLC ” Practice Location

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