1295034908 NPI number — UTAH VALLEY RADIOLOGY ASSOC

Table of content: (NPI 1295034908)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295034908 NPI number — UTAH VALLEY RADIOLOGY ASSOC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UTAH VALLEY RADIOLOGY ASSOC
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:
1295034908
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
283 E 930 S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OREM
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84058-5001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-225-6246
Provider Business Mailing Address Fax Number:
801-225-1525

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
380 W. 100 N.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTICELLO
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-225-6246
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/21/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BURGON
Authorized Official First Name:
JANELL
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING
Authorized Official Telephone Number:
801-701-6504

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 87028448008 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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