Basic Information
| Provider Information | |||||||||
| NPI: | 1528012770 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | U FAMILY HEALTH BILLING UNIVERSITY OF UTAH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UNIVERSITY DEPARTMENT OF FAMILY AND PREVENTATIVE MEDICINE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 510004 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841510004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015876600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 555 FOOTHILL DR | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841121106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015855382 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 09/06/2011 | ||||||||
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| AuthorizedOfficialLastName: | MAGILL | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | DEPARTMENT CHAIR | ||||||||
| AuthorizedOfficialTelephone: | 8015817294 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | CG9439 | 01 | RAILROAD | OTHER | 876000525706 | 05 | UT | MEDICAID | CC6626 | 01 | RAILROAD | OTHER | 100506044 | 05 | NV | MEDICAID | 807262100 | 05 | ID | MEDICAID |