1851484489 NPI number — MAX H SHURTLIFF CRNA

Table of content: MAX H SHURTLIFF CRNA (NPI 1851484489)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851484489 NPI number — MAX H SHURTLIFF CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHURTLIFF
Provider First Name:
MAX
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1851484489
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3618 W 6000 S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84067
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-993-9527
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3580 W 9000 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST JORDAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84070
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-993-9527
Provider Business Practice Location Address Fax Number:
801-733-5872
Provider Enumeration Date:
10/02/2006

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: 367500000X , with the licence number:  212191-4406 , 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: 102600 . This is a "GEM" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 293654 . This is a "DMBA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 39005 . This is a "PEHP" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 870542403 84121 A003 . This is a "TRICARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: PR00993 . This is a "MOLINA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: QMXAF01875 . This is a "ALTIUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 107001189102 . This is a "IHC" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 870542403SH1 . This is a "EDUCATORS MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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