MEDICARE: OLYMPUS FAMILY MEDICINE

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	261QP2300X	Primary Care Clinic/Center	98642974405	UT

General Provider Information

NPI Number	:	1053764431
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLYMPUS FAMILY MEDICINE

Provider Business Mailing Address
First Line	:	4624 S HOLLADAY BLVD STE 100
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-7054
Country	:	US
Telephone Number	:	801-277-2682
Fax Number	:

Provider Business Practice Location Address
First Line	:	4624 S HOLLADAY BLVD STE 100
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-7054
Country	:	US
Telephone Number	:	801-277-2682
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JARED PROBST
Credential	:	MD
Telephone Number	:	801-277-2682

Provider Enumeration Date	:	07/20/2016
Last Update Date	:	07/20/2016

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Directions to “OLYMPUS FAMILY MEDICINE ” Practice Location

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