Basic Information
| Provider Information | |||||||||
| NPI: | 1336406438 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALLEGIS CARE-UTAH, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1340 S DAMEN AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606081169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732924800 | ||||||||
| FaxNumber: | 3125644059 | ||||||||
| Practice Location | |||||||||
| Address1: | 10808 SOUTH RIVER ROAD | ||||||||
| Address2: | SUITE 344 | ||||||||
| City: | SOUTH JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840956103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732924800 | ||||||||
| FaxNumber: | 3125644059 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2012 | ||||||||
| LastUpdateDate: | 09/02/2015 | ||||||||
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| AuthorizedOfficialLastName: | WALES | ||||||||
| AuthorizedOfficialFirstName: | DIRK | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6155643511 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 207R00000X | UT | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.