Basic Information
| Provider Information | |||||||||
| NPI: | 1437251279 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AFTER HOURS MEDICAL LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEDALLUS MEDICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 95970 | ||||||||
| Address2: | |||||||||
| City: | SOUTH JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840950970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013529500 | ||||||||
| FaxNumber: | 8013529502 | ||||||||
| Practice Location | |||||||||
| Address1: | 1126 E 12300 S | ||||||||
| Address2: | |||||||||
| City: | DRAPER | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840209095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015450600 | ||||||||
| FaxNumber: | 8015450626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2006 | ||||||||
| LastUpdateDate: | 12/22/2016 | ||||||||
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| AuthorizedOfficialLastName: | VACHAROTHONE | ||||||||
| AuthorizedOfficialFirstName: | RACHOT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8012601919 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | UT | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1437251279 | 05 | UT | MEDICAID |