Healthcare Provider Details

I. General information

NPI: 1215010327
Provider Name (Legal Business Name): HIGHLAND MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 03/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4460 HIGHLAND DR STE 400
SALT LAKE CITY UT
84124-3565
US

IV. Provider business mailing address

4460 SO HIGHLAND DR #400
SALT LAKE CITY UT
84124
US

V. Phone/Fax

Practice location:
  • Phone: 801-272-4111
  • Fax: 801-272-5989
Mailing address:
  • Phone: 801-272-4111
  • Fax: 801-272-5989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3484061205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3655121205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number1813021205
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2763721206
License Number StateUT
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2879974405
License Number StateUT
# 6
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1045691206
License Number StateUT
# 7
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1813021205
License Number StateUT

VIII. Authorized Official

Name: DEREK DAVID MUSE
Title or Position: MANAGER
Credential: MD
Phone: 801-272-4111