NPIMap

Organization Active NPI

MMG LLC

  • Nurse Practitioner
  • Meridian, ID
National Provider Identifier
1407469166
Registry record updated Jul 22, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Nurse PractitionerTaxonomy code 363L00000X
Legal business name
MMG LLC
Practice address
2440 S Titanium PL
Meridian, ID 83642-6703
Phone
(208) 456-2659
Fax
(208) 454-0854
NPI assigned
Aug 24, 2020
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 22, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Kenneth E Norris
Title
Managing Partner
Phone
(801) 485-6166

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Nurse PractitionerGroup: 193400000X SINGLE SPECIALTY GROUP 363L00000X Primary

Addresses

Primary practice location

2440 S Titanium PL
Meridian, ID 83642-6703

Mailing address

450 S 900 E Ste 100
Salt Lake City, UT 84102-2983
Phone (801) 456-6166

Other names 1

  • Mobile Medical Group Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20201013002125 ID Part B Supplier - Clinic/Group Practice 5991039489 Receives reassigned benefits from 3 practitioners
Practice locations: Meridian, ID

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1598227200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658448000000",
    "number": "1407469166",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "450 S 900 E STE 100",
            "city": "SALT LAKE CITY",
            "state": "UT",
            "postal_code": "841022983",
            "telephone_number": "801-456-6166",
            "fax_number": "801-531-1949"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2440 S TITANIUM PL",
            "city": "MERIDIAN",
            "state": "ID",
            "postal_code": "836426703",
            "telephone_number": "208-456-2659",
            "fax_number": "208-454-0854"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MMG LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-08-24",
        "last_updated": "2022-07-22",
        "certification_date": "2022-07-22",
        "status": "A",
        "authorized_official_last_name": "NORRIS",
        "authorized_official_first_name": "KENNETH",
        "authorized_official_middle_name": "E",
        "authorized_official_title_or_position": "MANAGING PARTNER",
        "authorized_official_telephone_number": "801-485-6166"
    },
    "taxonomies": [
        {
            "code": "363L00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mobile Medical Group",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Mobile Medical Group",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Meridian, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 22, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.