1215918297 NPI number — GREGORY G PATCH MD

Employer Identification Number (EIN)	:
Provider Organization Name (Legal Business Name)	:
Provider Last Name (Legal Name)	:	PATCH
Provider First Name	:	GREGORY
Provider Middle Name	:	G
Provider Name Prefix Text	:
Provider Name Suffix Text	:
Provider Credential Text	:	MD
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	:
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NPI Number	:	1215918297
Entity Type Code	:	Individual
Replacement NPI	:
Last Update Date	:	07/08/2007
NPI Deactivation Reason Code	:
NPI Deactivation Date	:
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Provider First Line Business Mailing Address	:	PO BOX 345
Provider Second Line Business Mailing Address	:
Provider Business Mailing Address City Name	:	BOUNTIFUL
Provider Business Mailing Address State Name	:	UT
Provider Business Mailing Address Postal Code	:	840110345
Provider Business Mailing Address Country Code	:	US
Provider Business Mailing Address Telephone Number	:	8012923212
Provider Business Mailing Address Fax Number	:

Provider First Line Business Practice Location Address	:	630 MEDICAL DR
Provider Second Line Business Practice Location Address	:
Provider Business Practice Location Address City Name	:	BOUNTIFUL
Provider Business Practice Location Address State Name	:	UT
Provider Business Practice Location Address Postal Code	:	840104908
Provider Business Practice Location Address Country Code	:	US
Provider Business Practice Location Address Telephone Number	:	8012923212
Provider Business Practice Location Address Fax Number	:
Provider Enumeration Date	:	11/08/2005

Authorized Official Last Name	:
Authorized Official First Name	:
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• Taxonomy code: 2085R0202X , with the licence number:  180827-1205 , registered in the state of UT .

• Identifier: D0957 , issued by the state of ( UT ) . This identifiers is of the category "".
• Identifier: B63906 . This identifiers is of the category "".