1063513596 NPI number — DR. CONSTANCE K MAVES MD

Table of content: DR. CONSTANCE K MAVES MD (NPI 1063513596)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063513596 NPI number — DR. CONSTANCE K MAVES MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAVES
Provider First Name:
CONSTANCE
Provider Middle Name:
K
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063513596
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
869 E 4500 S
Provider Second Line Business Mailing Address:
PMB 511
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84107-3049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-487-0451
Provider Business Mailing Address Fax Number:
801-487-2467

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 N MEDICAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84113-1103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-662-1900
Provider Business Practice Location Address Fax Number:
801-662-1810
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085P0229X , with the licence number:  5010881-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1070011544101 . This is a "SELECTHEALTH" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 1600468 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 50108811200001 . This is a "BLUE SHIELD" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 67154 . This is a "PUBLIC EMPLOYEES HEALTH" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 870355724MAV . This is a "EDUCATORS MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 8550895 . This is a "AETNA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 31853 . This is a "UUHN" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 35834 . This is a "DESERET MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: QM0000027099 . This is a "ALTIUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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