Basic Information
| Provider Information | |||||||||
| NPI: | 1376597344 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UTAH HEALTHCARE INSTITUTE INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. MARK'S FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1250 E 3900 S | ||||||||
| Address2: | SUITE 260 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841241348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012652000 | ||||||||
| FaxNumber: | 8012652008 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 E 3900 S | ||||||||
| Address2: | SUITE 260 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841241348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012652000 | ||||||||
| FaxNumber: | 8012652008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 12/07/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BERNEIKE | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR/OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8012652000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1376597344 | 05 | UT | MEDICAID |