Healthcare Provider Details

I. General information

NPI: 1912925629
Provider Name (Legal Business Name): ST MARK'S PROFESSIONAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 02/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E 3900 S
SALT LAKE CITY UT
84124-1300
US

IV. Provider business mailing address

PO BOX 271220
SALT LAKE CITY UT
84127-1220
US

V. Phone/Fax

Practice location:
  • Phone: 801-268-7860
  • Fax: 801-270-3331
Mailing address:
  • Phone: 801-268-7860
  • Fax: 801-270-3331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: STEVE BATEMAN
Title or Position: CEO
Credential:
Phone: 801-268-7700