1881801579 NPI number — SAMANTHA P BOSTROM MD

Table of content: SAMANTHA P BOSTROM MD (NPI 1881801579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881801579 NPI number — SAMANTHA P BOSTROM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOSTROM
Provider First Name:
SAMANTHA
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PIKE BOSTROM
Provider Other First Name:
SAMANTHA
Provider Other Middle Name:
N
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1881801579
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1477 NORTH 2000 WEST
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
CLINTON
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84015-8213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-774-8888
Provider Business Mailing Address Fax Number:
801-825-8519

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1477 NORTH 2000 WEST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
CLINTON
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84015-8213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-774-8888
Provider Business Practice Location Address Fax Number:
801-825-8519
Provider Enumeration Date:
05/16/2007

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: 208000000X , with the licence number:  327457-1205 , 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: D2612 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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