Provider Demographics
NPI:1053764431
Name:OLYMPUS FAMILY MEDICINE
Entity type:Organization
Organization Name:OLYMPUS FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:PROBST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-277-2682
Mailing Address - Street 1:4624 S HOLLADAY BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-7054
Mailing Address - Country:US
Mailing Address - Phone:801-277-2682
Mailing Address - Fax:
Practice Address - Street 1:4624 S HOLLADAY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-7054
Practice Address - Country:US
Practice Address - Phone:801-277-2682
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT98642974405261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care