Basic Information
| Provider Information | |||||||||
| NPI: | 1437267192 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEREMER | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5405 S 500 E | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844056957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014758600 | ||||||||
| FaxNumber: | 8014758686 | ||||||||
| Practice Location | |||||||||
| Address1: | 5405 S 500 E | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844056957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014758600 | ||||||||
| FaxNumber: | 8014758686 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 09/09/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 320722-1205 | UT | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 320722-1205 | UT | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 1437267192 | 05 | UT | MEDICAID |