Basic Information
| Provider Information | |||||||||
| NPI: | 1104127901 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IHC HEALTH SERVICES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UTAH VALLEY HYPERBARIC AND WOUND CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27128 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841270128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013578156 | ||||||||
| FaxNumber: | 8013578156 | ||||||||
| Practice Location | |||||||||
| Address1: | 395 W COUGAR BLVD STE 101 | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013578156 | ||||||||
| FaxNumber: | 8013578156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2010 | ||||||||
| LastUpdateDate: | 01/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRIESACHER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SVP-CHIEF PHY EXECUTIVE | ||||||||
| AuthorizedOfficialTelephone: | 8014423495 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 01/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083P0011X | 8802010 | UT | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Undersea and Hyperbaric Medicine |
No ID Information.