Basic Information
| Provider Information | |||||||||
| NPI: | 1487198321 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UTAH PLASTIC SURGERY LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | UTAH FACIAL PLASTICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2255 N 1700 W | ||||||||
| Address2: | #205 | ||||||||
| City: | LAYTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840411119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017762220 | ||||||||
| FaxNumber: | 8017762534 | ||||||||
| Practice Location | |||||||||
| Address1: | 2255 N 1700 W | ||||||||
| Address2: | #205 | ||||||||
| City: | LAYTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840411119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017762220 | ||||||||
| FaxNumber: | 8017762534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2016 | ||||||||
| LastUpdateDate: | 12/12/2016 | ||||||||
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| AuthorizedOfficialLastName: | THOMPSON | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | KENT | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8017762220 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YS0123X | 6103240-1205 | UT | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Facial Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 529599912001 | 05 | UT | MEDICAID |