Basic Information
| Provider Information | |||||||||
| NPI: | 1366436768 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EGBERT | ||||||||
| FirstName: | LARRE | ||||||||
| MiddleName: | DEAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1098 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846531098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014233306 | ||||||||
| FaxNumber: | 8014233309 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 E 100 N | ||||||||
| Address2: | |||||||||
| City: | PAYSON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846511600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014657190 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2005 | ||||||||
| LastUpdateDate: | 10/07/2013 | ||||||||
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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 | 207P00000X | 178379-1205 | UT | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 09220 | 05 | UT | MEDICAID |