1083619043 NPI number — DR. J. BRYAN ELLSWORTH M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083619043 NPI number — DR. J. BRYAN ELLSWORTH M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

ELLSWORTH

Provider First Name:

J.

Provider Middle Name:

BRYAN

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

M

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:

1083619043

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

06/16/2022

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

736 S 900 E STE 108

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

ST GEORGE

Provider Business Mailing Address State Name:

UT

Provider Business Mailing Address Postal Code:

84790-7002

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

435-628-3606

Provider Business Mailing Address Fax Number:

435-628-8404

Provider First Line Business Practice Location Address:

736 S 900 E STE 108

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

ST GEORGE

Provider Business Practice Location Address State Name:

UT

Provider Business Practice Location Address Postal Code:

84790

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

435-628-3606

Provider Business Practice Location Address Fax Number:

435-628-8404

Provider Enumeration Date:

06/16/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 208800000X , with the licence number:  15297 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 174400000X , with the licence number: 188550-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 005575530 . This is a "HUMANA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 6411882 . This is a "CIGNA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 751575 . This is a "DMBA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 870562879ELL . This is a "EMIA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: V108245 . This is a "MEDICARE ID FOR NEVADA PRACTICE LOCATION" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
• Identifier: 68471 . This is a "PEHP" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 18855012000001 . This is a "BC BS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 340020123 . This is a "RR MEDICARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 107011798101 . This is a "IHC" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: QM0000076522 . This is a "ALTIUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".