1609984988 NPI number — ELWOOD J CORRY JR. MD

Table of content: ELWOOD J CORRY JR. MD (NPI 1609984988)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609984988 NPI number — ELWOOD J CORRY JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORRY
Provider First Name:
ELWOOD
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
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:
1609984988
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
830 N 2000 W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLEASANT GROVE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84062-4047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-756-3511
Provider Business Mailing Address Fax Number:
801-443-1164

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
830 N 2000 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLEASANT GROVE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84062-4047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-756-3511
Provider Business Practice Location Address Fax Number:
801-443-1164
Provider Enumeration Date:
08/28/2006

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: 207Q00000X , with the licence number:  1764831205 , 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: 08829 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 17643 . This is a "PEHP" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: QM0000000728 . This is a "ALTIUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 107006223101 . This is a "SELECT HEALTH" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 2657 . This is a "DESERET HEALTHCARE TRUST" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 87029387384062B005 . This is a "TRICARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 870293873C01 . This is a "EMI HEALTH" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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