Healthcare Provider Details

I. General information

NPI: 1982871828
Provider Name (Legal Business Name): ST. MARK'S SOUTH JORDAN FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2008
Last Update Date: 05/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10623 S REDWOOD RD SUITE 101
SOUTH JORDAN UT
84095-2481
US

IV. Provider business mailing address

10623 S REDWOOD RD SUITE 101
SOUTH JORDAN UT
84095-2481
US

V. Phone/Fax

Practice location:
  • Phone: 801-302-0899
  • Fax: 801-302-0892
Mailing address:
  • Phone: 801-302-0899
  • Fax: 801-302-0892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID J. KANE
Title or Position: VP
Credential:
Phone: 801-568-5999