1558690610 NPI number — JOSEPH D HILLAM MD A PROFESSIONAL CORP

Table of content: (NPI 1558690610)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558690610 NPI number — JOSEPH D HILLAM MD A PROFESSIONAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOSEPH D HILLAM MD A PROFESSIONAL CORP
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:
1558690610
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
990 MEDICAL DRIVE
Provider Second Line Business Mailing Address:
SUITE U2
Provider Business Mailing Address City Name:
BRIGHAM CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84302-4714
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-734-9439
Provider Business Mailing Address Fax Number:
435-723-0267

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
990 MEDICAL DR
Provider Second Line Business Practice Location Address:
SUITE U2
Provider Business Practice Location Address City Name:
BRIGHAM CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84302-4713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-734-9439
Provider Business Practice Location Address Fax Number:
435-723-0267
Provider Enumeration Date:
12/18/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HILLAM
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
435-734-9439

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  1529431205 , 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: 528620884009 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".