1821109026 NPI number — JOHN BENSON EGAN PT

Table of content: JOHN BENSON EGAN PT (NPI 1821109026)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821109026 NPI number — JOHN BENSON EGAN PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EGAN
Provider First Name:
JOHN
Provider Middle Name:
BENSON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1821109026
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 711185
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84171-1185
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-942-3311
Provider Business Mailing Address Fax Number:
801-942-5955

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
698 E 12TH ST
Provider Second Line Business Practice Location Address:
STE 300
Provider Business Practice Location Address City Name:
OGDEN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84404-6200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-782-0300
Provider Business Practice Location Address Fax Number:
801-782-0305
Provider Enumeration Date:
08/31/2006

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: 225100000X , with the licence number:  32G1852401 , 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: 1821109026 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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