Provider Demographics
NPI:1487016226
Name:BLUE SAGE MEDICAL LLC
Entity type:Organization
Organization Name:BLUE SAGE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGPCNP
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:COCCIMIGLIO
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:801-718-7280
Mailing Address - Street 1:6300 SAGEWOOD DR
Mailing Address - Street 2:SUITE H-532
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-7502
Mailing Address - Country:US
Mailing Address - Phone:801-718-7280
Mailing Address - Fax:888-853-5162
Practice Address - Street 1:6300 SAGEWOOD DR
Practice Address - Street 2:SUITE H-532
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-7502
Practice Address - Country:US
Practice Address - Phone:801-718-7280
Practice Address - Fax:888-853-5162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-22
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT123071-4405363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty