Organization
MOUNTAIN MEDICAL PHYSICIAN SPECIALISTS OF IDAHO PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CLARK A DAVIS (CEO)
(801) 284-1705
Entity
Organization
Contact information
Practice address
1501 HILAND AVE, BURLEY, ID 83318-2682
(801) 284-1755
(801) 262-3897
Mailing address
5444 GREEN ST, MURRAY, UT 84123-5632
(801) 284-1755
(801) 262-3897
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
C176456
ID
Other
Enumeration date
01/17/2008
Last updated
11/12/2008
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