1922115963 NPI number — UNIVERSITY OF UTAH PAIN MANAGEMENT PHYSICIANS GROUP

Table of content: AKETZALLI GAMEZ LIZARRAGA D. M. D. (NPI 1073006243)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922115963 NPI number — UNIVERSITY OF UTAH PAIN MANAGEMENT PHYSICIANS GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNIVERSITY OF UTAH PAIN MANAGEMENT PHYSICIANS GROUP
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:
1922115963
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 413034
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:
84141-3034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-213-3900
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
546 S CHIPETA WAY
Provider Second Line Business Practice Location Address:
220
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84108-1221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-581-7172
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CAHALAN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
K
Authorized Official Title or Position:
DEPARTMENT CHAIR
Authorized Official Telephone Number:
801-581-6393

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100502709 . This is a "NEVADA MEDICAID" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 172970100 . This is a "DEPT OF LABOR" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 122767000 . This is a "WYOMING MEDICAID" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 806360300 . This is a "IDAHO MEDICAID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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