Basic Information
| Provider Information | |||||||||
| NPI: | 1710944293 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RINDFLESH | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ALEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 413076 | ||||||||
| Address2: | UUNI | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841413076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015876688 | ||||||||
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| Practice Location | |||||||||
| Address1: | 501 CHIPETA WAY | ||||||||
| Address2: | UUNI | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015873210 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 11/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P2900X | 6062A | WY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Pain Medicine | 2084P2900X | 1573651205 | UT | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 11342000 | 05 | WY | MEDICAID |