Healthcare Provider Details

I. General information

NPI: 1720035520
Provider Name (Legal Business Name): MOUNTAIN MEDICAL PHYSICIAN SPECIALISTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5334 S WOODROW ST STE 101
MURRAY UT
84107-5838
US

IV. Provider business mailing address

5334 S WOODROW ST STE 101
MURRAY UT
84107-5838
US

V. Phone/Fax

Practice location:
  • Phone: 801-284-1755
  • Fax:
Mailing address:
  • Phone: 801-284-1755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number1328836-0144
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number1328836-0144
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number1328836-0144
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number1328836-0144
License Number StateUT
# 5
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number1328836-0144
License Number StateUT

VIII. Authorized Official

Name: JULIE PENROD
Title or Position: CEO
Credential:
Phone: 801-284-1705