1174705198 NPI number — THOMAS D MYERS MD PC

Table of content: (NPI 1174705198)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174705198 NPI number — THOMAS D MYERS MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THOMAS D MYERS MD PC
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:
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:
1174705198
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
280 RIVER PARK DR
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
PROVO
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84604-5764
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-224-3565
Provider Business Mailing Address Fax Number:
801-224-3567

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
280 RIVER PARK DR
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
PROVO
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84604-5764
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-224-3565
Provider Business Practice Location Address Fax Number:
801-224-3567
Provider Enumeration Date:
11/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MYERS
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
DYRENG
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
801-224-3565

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  52144401205 , 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)





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