1215239348 NPI number — JON LEROY PERTAB PH.D.

Table of content: JON LEROY PERTAB PH.D. (NPI 1215239348)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215239348 NPI number — JON LEROY PERTAB PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PERTAB
Provider First Name:
JON
Provider Middle Name:
LEROY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

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:
1215239348
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5171 SOUTH COTTONWOOD ST SUITE 810
Provider Second Line Business Mailing Address:
NEUROSCIENCES INSTITUTE,
Provider Business Mailing Address City Name:
MURRAY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-507-9800
Provider Business Mailing Address Fax Number:
801-507-9800

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5171 SOUTH COTTONWOOD ST SUITE 810
Provider Second Line Business Practice Location Address:
NEUROSCIENCES INSTITUTE,
Provider Business Practice Location Address City Name:
MURRAY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-507-9800
Provider Business Practice Location Address Fax Number:
801-507-9800
Provider Enumeration Date:
11/22/2010

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: 103G00000X , with the licence number:  7759498-2501 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: 7759498-2501 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: 7759498-2501 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TH0004X , with the licence number: 7759498-2501 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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