1043466899 NPI number — DR. JILL BERGESON BARKDULL M.D.

Table of content: DR. JILL BERGESON BARKDULL M.D. (NPI 1043466899)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043466899 NPI number — DR. JILL BERGESON BARKDULL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERGESON BARKDULL
Provider First Name:
JILL
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1043466899
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:
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:
801-756-1705
Provider Business Practice Location Address Fax Number:
801-443-1164
Provider Enumeration Date:
08/12/2008

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:  57647571205 , 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: 171564 . This is a "PEHP" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 870293878 . This is a "EMI HEALTH" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 107107195101 . This is a "SELECT HEALTH" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 1043466899 . This is a "ALTIUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 1043466899 . This is a "TRICARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 1043466899 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1126140 . This is a "DESERET HEALTHCARE TRUST" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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