Basic Information
| Provider Information | |||||||||
| NPI: | 1215918297 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATCH | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25488 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841250488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004753698 | ||||||||
| FaxNumber: | 8012966199 | ||||||||
| Practice Location | |||||||||
| Address1: | 1433 N 1075 W STE 104 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840252746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012992200 | ||||||||
| FaxNumber: | 8012966199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 02/26/2019 | ||||||||
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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 | 207U00000X | 180827-1205 | UT | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | 2085R0202X | 180827-1205 | UT | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 266077 | 01 | UT | DESERET MUTUAL BENEFITS ADMINISTRATORS | OTHER | 300064158 | 01 | UT | RAILROAD MEDICARE | OTHER | D0957 | 05 | UT | MEDICAID | 107007749104 | 01 | UT | SELECTHEALTH | OTHER |