Basic Information
Provider Information | |||||||||
NPI: | 1063522589 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCALLISTER | ||||||||
FirstName: | BRADLEY | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3340 NORTH CENTER ST #800 | ||||||||
Address2: |   | ||||||||
City: | LEHI | ||||||||
State: | UT | ||||||||
PostalCode: | 840437406 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8019901911 | ||||||||
FaxNumber: | 8019901912 | ||||||||
Practice Location | |||||||||
Address1: | 8TH AVENUE AND C STREET | ||||||||
Address2: | LDS HOSPITAL | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 84143 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8015075248 | ||||||||
FaxNumber: | 8017335618 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/30/2006 | ||||||||
LastUpdateDate: | 10/15/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 185405-1205 | UT | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 001563700 | 05 | ID |   | MEDICAID | 107005855101 | 01 | UT | IHC | OTHER | 820648 | 05 | AZ |   | MEDICAID | 37804 | 01 | UT | PEHP | OTHER | 53254 | 01 | UT | HEALTHY U | OTHER | QM0000075886 | 01 | UT | ALTIUS | OTHER | 8597445 | 01 | UT | WORKERS COMP | OTHER | 870545614MC1 | 01 | UT | EDUCATORS MUTUAL | OTHER | PRA01569 | 01 | UT | MOLINA | OTHER | 002083525 | 05 | WY |   | MEDICAID | 2090168 | 01 | UT | UNITED HEALTHCARE | OTHER | 1502954 | 01 | UT | UMWA | OTHER |