1902875669 NPI number — NORTHERN UTAH ENDOSCOPY CENTER

Table of content: (NPI 1902875669)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902875669 NPI number — NORTHERN UTAH ENDOSCOPY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN UTAH ENDOSCOPY CENTER
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:
NORTHERN UTAH ENDOSCOPY CENTER, LLC
Provider Other Organization Name Type Code:
5
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:
1902875669
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
630 E 1400 N
Provider Second Line Business Mailing Address:
SUITE 100A
Provider Business Mailing Address City Name:
LOGAN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84341-2534
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-787-0270
Provider Business Mailing Address Fax Number:
435-787-0262

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
630 E 1400 N
Provider Second Line Business Practice Location Address:
SUITE 100A
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84341-2534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-787-0270
Provider Business Practice Location Address Fax Number:
435-787-0262
Provider Enumeration Date:
03/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOHMAN
Authorized Official First Name:
DUANE
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
435-787-0270

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  2006-ASF-16794 , 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: 490004876 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 2006-ASF-16794 . This is a "STATE LICENSE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 806091700 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 116023100 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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