1184150013 NPI number — SALT LAKE SURGICAL SERVICES PLLC

Table of content: (NPI 1184150013)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184150013 NPI number — SALT LAKE SURGICAL SERVICES PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SALT LAKE SURGICAL SERVICES PLLC
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:
THE SURGICALIST GROUP, PLLC
Provider Other Organization Name Type Code:
3
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:
1184150013
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 21647
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33622-1647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-530-5043
Provider Business Mailing Address Fax Number:
813-530-5043

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1492 W ANTELOPE DR STE 209
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAYTON
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84041-1158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
385-429-3535
Provider Business Practice Location Address Fax Number:
385-429-3515
Provider Enumeration Date:
05/11/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DESAI
Authorized Official First Name:
MIT
Authorized Official Middle Name:
NAVANIT
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
813-530-5043

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)