Basic Information
| Provider Information | |||||||||
| NPI: | 1215001037 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KANE COUNTY HUMAN RESOURCE SPECIAL SERVICE DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KANE COUNTY MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 355 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | KANAB | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847413260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356444100 | ||||||||
| FaxNumber: | 4356444197 | ||||||||
| Practice Location | |||||||||
| Address1: | 355 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | KANAB | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847413260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356444100 | ||||||||
| FaxNumber: | 4356444197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MITCHELL | ||||||||
| AuthorizedOfficialFirstName: | TOM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4356445811 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 87600030002001 | 01 | BCBS | OTHER |