Basic Information
| Provider Information | |||||||||
| NPI: | 1346489036 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEAK ENT ASSOCIATES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THYROID INSTITUTE OF UTAH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 300 W | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013577499 | ||||||||
| FaxNumber: | 8013735980 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 N 300 W | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013577499 | ||||||||
| FaxNumber: | 8013735980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2009 | ||||||||
| LastUpdateDate: | 03/30/2012 | ||||||||
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| AuthorizedOfficialLastName: | PRUSSE | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8013577499 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YX0602X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngic Allergy | 231H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207RE0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 207YX0901X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Otology & Neurotology | 207YX0905X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery |
No ID Information.