Basic Information
| Provider Information | |||||||||
| NPI: | 1295034908 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UTAH VALLEY RADIOLOGY ASSOC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 283 E 930 S | ||||||||
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| City: | OREM | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840585001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012256246 | ||||||||
| FaxNumber: | 8012251525 | ||||||||
| Practice Location | |||||||||
| Address1: | 380 W. 100 N. | ||||||||
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| City: | MONTICELLO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012256246 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2011 | ||||||||
| LastUpdateDate: | 03/21/2011 | ||||||||
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| AuthorizedOfficialLastName: | BURGON | ||||||||
| AuthorizedOfficialFirstName: | JANELL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 8017016504 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 87028448008 | 05 | UT | MEDICAID |