Basic Information
| Provider Information | |||||||||
| NPI: | 1790794063 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLINES | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 271220 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841271220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015341360 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1250 E 3900 S | ||||||||
| Address2: | #30 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012687725 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 08/07/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 7596444-1205 | UT | N | Allopathic & Osteopathic Physicians | Anesthesiology | 208VP0014X | 7596444-1205 | UT | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1790794063 | 05 | UT | MEDICAID |