Provider Demographics
NPI:1083461917
Name:UTAH PROVIDER GROUP
Entity type:Organization
Organization Name:UTAH PROVIDER GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:UDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-515-0088
Mailing Address - Street 1:1506 S SILICON WAY STE 2B
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-7153
Mailing Address - Country:US
Mailing Address - Phone:888-920-7526
Mailing Address - Fax:
Practice Address - Street 1:1506 S SILICON WAY STE 2B
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-7153
Practice Address - Country:US
Practice Address - Phone:888-920-7526
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-30
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care