1063651669 NPI number — UINTAH BASIN MEDICAL CENTER

Table of content: (NPI 1063651669)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063651669 NPI number — UINTAH BASIN MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UINTAH BASIN MEDICAL 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:
Provider Other Organization Name Type Code:
6
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:
1063651669
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/17/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 905
Provider Second Line Business Mailing Address:
50 EAST 200 SOUTH
Provider Business Mailing Address City Name:
DUCHESNE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84021-0905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-738-5403
Provider Business Mailing Address Fax Number:
435-738-5405

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 EAST 200 SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUCHESNE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-738-5403
Provider Business Practice Location Address Fax Number:
435-738-5405
Provider Enumeration Date:
02/05/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HALES
Authorized Official First Name:
BRENT
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
435-722-6164

Provider Taxonomy Codes

  • Taxonomy code: 3336C0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 7263753-1703 , 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: 4611249 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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