Basic Information
Provider Information | |||||||||
NPI: | 1598763112 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOYER | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | WAYNE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 295 CHIPETA WAY | ||||||||
Address2: | UOFU DEPT OF PEDIATRICS-HEMONC | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841081220 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8015877400 | ||||||||
FaxNumber: | 8015877417 | ||||||||
Practice Location | |||||||||
Address1: | 100 N MEDICAL DR | ||||||||
Address2: | BMT | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841131103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8015853229 | ||||||||
FaxNumber: | 8015853432 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/08/2005 | ||||||||
LastUpdateDate: | 01/31/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 6150957-1205 | UT | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 2080P0207X | 6150957-1205 | UT | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology |
ID Information
ID | Type | State | Issuer | Description | 123768300 | 05 | WY |   | MEDICAID | 2162341 | 05 | OH |   | MEDICAID | 64006950 | 05 | KY |   | MEDICAID | 0157063 | 05 | MT |   | MEDICAID | 100510358 | 05 | NV |   | MEDICAID | 0157053 | 05 | MT |   | MEDICAID | D6692 | 05 | UT |   | MEDICAID | 807569000 | 05 | ID |   | MEDICAID |