Basic Information
Provider Information | |||||||||
NPI: | 1033240965 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | IHC HEALTH SERVICES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MCKAY DEE SPORTS MEDICINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 27128 | ||||||||
Address2: |   | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841270128 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8013872775 | ||||||||
FaxNumber: | 8013872780 | ||||||||
Practice Location | |||||||||
Address1: | 4401 HARRISON BLVD STE 2440 | ||||||||
Address2: |   | ||||||||
City: | OGDEN | ||||||||
State: | UT | ||||||||
PostalCode: | 844033195 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8013872775 | ||||||||
FaxNumber: | 8013872780 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/09/2007 | ||||||||
LastUpdateDate: | 07/31/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LECKMAN | ||||||||
AuthorizedOfficialFirstName: | LINDA | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | CEO INTERMOUNTAIN MEDICAL GROUP | ||||||||
AuthorizedOfficialTelephone: | 8014423974 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081S0010X | 1001282 | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine |
No ID Information.