Basic Information
Provider Information | |||||||||
NPI: | 1356687784 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MOUNT ZION ANESTHESIA LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1847 | ||||||||
Address2: |   | ||||||||
City: | GILBERT | ||||||||
State: | AZ | ||||||||
PostalCode: | 852991847 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4805072961 | ||||||||
FaxNumber: | 4805072971 | ||||||||
Practice Location | |||||||||
Address1: | 3580 W 9000 S | ||||||||
Address2: |   | ||||||||
City: | WEST JORDAN | ||||||||
State: | UT | ||||||||
PostalCode: | 840888812 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8015618888 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/12/2012 | ||||||||
LastUpdateDate: | 07/06/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WRIGHT | ||||||||
AuthorizedOfficialFirstName: | JEFFREY | ||||||||
AuthorizedOfficialMiddleName: | LOWELL | ||||||||
AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
AuthorizedOfficialTelephone: | 8018703884 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 4922501-1205 | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | DU5531 | 01 | UT | MEDICARE RR | OTHER | FW2686840 | 01 |   | DEA | OTHER |