1972503696 NPI number — UTAH DIGESTIVE HEALTH INSTITUTE

Table of content: (NPI 1972503696)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972503696 NPI number — UTAH DIGESTIVE HEALTH INSTITUTE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UTAH DIGESTIVE HEALTH INSTITUTE
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:
1972503696
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
08/02/2005
NPI Reactivation Date:
08/24/2007

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6028 S RIDGELINE DR
Provider Second Line Business Mailing Address:
#201
Provider Business Mailing Address City Name:
OGDEN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84405-6914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-475-5400
Provider Business Mailing Address Fax Number:
801-475-8614

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6028 S RIDGELINE DR
Provider Second Line Business Practice Location Address:
#201
Provider Business Practice Location Address City Name:
OGDEN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84405-6914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-475-5400
Provider Business Practice Location Address Fax Number:
801-475-8614
Provider Enumeration Date:
07/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LOWE
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
E
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
801-475-5400

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 48268889301001 . This is a "REGENCE BLUE CROSS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 107006015101 . This is a "IHC" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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