Basic Information
| Provider Information | |||||||||
| NPI: | 1841433927 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRAL UTAH CLINIC, P.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | REVERE HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 500 W | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013548225 | ||||||||
| FaxNumber: | 8014180941 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 S 1000 E | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | PAYSON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846515590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014652511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2009 | ||||||||
| LastUpdateDate: | 03/07/2018 | ||||||||
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| AuthorizedOfficialLastName: | HARSTON | ||||||||
| AuthorizedOfficialFirstName: | JED | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF MANAGED CARE | ||||||||
| AuthorizedOfficialTelephone: | 8018125012 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.