1164530903 NPI number — RICHARDS GENERAL SURGERY PC

Table of content: (NPI 1164530903)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164530903 NPI number — RICHARDS GENERAL SURGERY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RICHARDS GENERAL SURGERY PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1164530903
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5249 GRAVENSTEIN PARK
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MURRAY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84123-4562
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-262-2830
Provider Business Mailing Address Fax Number:
888-893-1576

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
175 N 100 W
Provider Second Line Business Practice Location Address:
STE 202
Provider Business Practice Location Address City Name:
VERNAL
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84078-2049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-789-4180
Provider Business Practice Location Address Fax Number:
435-781-1185
Provider Enumeration Date:
08/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RICHARDS
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
TAYLOR
Authorized Official Title or Position:
ONWER/OPERATOR
Authorized Official Telephone Number:
801-262-2830

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  5586768-1205 , 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: 396421983001 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 55878120001 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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