Basic Information
| Provider Information | |||||||||
| NPI: | 1366624991 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NATHAN G MOMBERGER MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5848 FASHION BLVD STE 110 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841076121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013145026 | ||||||||
| FaxNumber: | 8013144015 | ||||||||
| Practice Location | |||||||||
| Address1: | 5848 FASHION BLVD STE 110 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841076121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013145026 | ||||||||
| FaxNumber: | 8013144015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2007 | ||||||||
| LastUpdateDate: | 11/10/2010 | ||||||||
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| AuthorizedOfficialLastName: | OAKES | ||||||||
| AuthorizedOfficialFirstName: | GENE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8013145026 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0114X | 3208681205 | UT | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 528299949009 | 05 | UT | MEDICAID |