Basic Information
| Provider Information | |||||||||
| NPI: | 1023005808 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PUGH | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | W | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6028 S RIDGELINE DR | ||||||||
| Address2: | STE 201 | ||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844056914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014755400 | ||||||||
| FaxNumber: | 8014758614 | ||||||||
| Practice Location | |||||||||
| Address1: | 6028 S RIDGELINE DR | ||||||||
| Address2: | STE 201 | ||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844056914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014755400 | ||||||||
| FaxNumber: | 8014758614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2005 | ||||||||
| LastUpdateDate: | 09/23/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 3619881204 | UT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 2900043 | 01 | UNITED HEALTHCARE | OTHER | 870653164002 | 05 | UT | MEDICAID | 107008467101 | 01 | IHC | OTHER |