Provider Demographics
NPI:1548683410
Name:MARK MILES PASSEY MD PC
Entity type:Organization
Organization Name:MARK MILES PASSEY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:MILES
Authorized Official - Last Name:PASSEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-314-2308
Mailing Address - Street 1:48 W BROADWAY APT 2001
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101-2015
Mailing Address - Country:US
Mailing Address - Phone:801-314-2308
Mailing Address - Fax:
Practice Address - Street 1:5872 S 900 E
Practice Address - Street 2:250
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-1676
Practice Address - Country:US
Practice Address - Phone:801-314-2308
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-29
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT81-167082-1205261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain