Basic Information
| Provider Information | |||||||||
| NPI: | 1336109891 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CREAGER | ||||||||
| FirstName: | DICK | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 144 S 500 E | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841021907 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3460 PIONEER PKWY | ||||||||
| Address2: | |||||||||
| City: | WEST VALLEY CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841202049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019643100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 04/22/2010 | ||||||||
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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 | 207PE0004X | 170837-1205 | UT | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207P00000X | 170837-1205 | UT | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | D0766 | 05 | UT | MEDICAID |