Provider Demographics
NPI:1861714768
Name:MTD MEDICAL SERVICES, LLC
Entity type:Organization
Organization Name:MTD MEDICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:FROHSE
Authorized Official - Last Name:KOEHLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-716-5489
Mailing Address - Street 1:290 N RED SLIDE DR
Mailing Address - Street 2:
Mailing Address - City:WELLSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84339-9757
Mailing Address - Country:US
Mailing Address - Phone:435-716-5489
Mailing Address - Fax:435-716-5442
Practice Address - Street 1:290 N RED SLIDE DR
Practice Address - Street 2:
Practice Address - City:WELLSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84339-9757
Practice Address - Country:US
Practice Address - Phone:435-716-5489
Practice Address - Fax:435-716-5442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT180791-1205207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTB61883Medicare UPIN