Basic Information
| Provider Information | |||||||||
| NPI: | 1669420014 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IHC HEALTH SERVICES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | AMERICAN FORK HOSPITAL PHYSICIAN GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4646 LAKE PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841208212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014428468 | ||||||||
| FaxNumber: | 8014420066 | ||||||||
| Practice Location | |||||||||
| Address1: | 170 N 1100 E | ||||||||
| Address2: | |||||||||
| City: | AMERICAN FORK | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840032096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017633520 | ||||||||
| FaxNumber: | 8018553186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 01/28/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LISONBEE | ||||||||
| AuthorizedOfficialFirstName: | RODNEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8013577212 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WD0400X | UT | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Diabetes Educator | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.