1629063755 NPI number — MICHAEL C CODY MD

Table of content: AMY BURBAGE PH.D (NPI 1104061605)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629063755 NPI number — MICHAEL C CODY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CODY
Provider First Name:
MICHAEL
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1629063755
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/26/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
520 MEDICAL DR
Provider Second Line Business Mailing Address:
SUITE #310
Provider Business Mailing Address City Name:
BOUNTIFUL
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84010-4968
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-397-3000
Provider Business Mailing Address Fax Number:
801-397-0455

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2132 NORTH 1700 WEST
Provider Second Line Business Practice Location Address:
SUITE #200
Provider Business Practice Location Address City Name:
LAYTON
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84041-1130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-776-0174
Provider Business Practice Location Address Fax Number:
801-825-3904
Provider Enumeration Date:
09/14/2005

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: 207RC0000X , with the licence number:  327424-1205 , 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: 1477643179 . This is a "GROUP NPI" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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