Basic Information
Provider Information | |||||||||
NPI: | 1881706752 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MYERS | ||||||||
FirstName: | KELLY | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3340 NORTH CENTER ST | ||||||||
Address2: | #800 | ||||||||
City: | LEHI | ||||||||
State: | UT | ||||||||
PostalCode: | 840437406 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8019901911 | ||||||||
FaxNumber: | 8019901912 | ||||||||
Practice Location | |||||||||
Address1: | 5121 S COTTONWOOD STREET | ||||||||
Address2: | INTERMOUNTAIN MEDICAL CENTER | ||||||||
City: | MURRAY | ||||||||
State: | UT | ||||||||
PostalCode: | 84157 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8015075248 | ||||||||
FaxNumber: | 8017335618 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2006 | ||||||||
LastUpdateDate: | 10/15/2012 | ||||||||
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 | 207L00000X | 94-276194-1205 | UT | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 2090168 | 01 | UT | UNITED HEALTHCARE | OTHER | 8597445 | 01 | UT | WORKERS COMP | OTHER | 310745 | 01 | UT | DESERET MUTUAL | OTHER | 44543 | 01 | UT | PEHP | OTHER | 7662 | 01 | UT | HEALTHY U | OTHER | 805588700 | 05 | ID |   | MEDICAID | QM0000075886 | 01 | UT | ALTIUS | OTHER | 115800700 | 05 | WY |   | MEDICAID | 1502954 | 01 | UT | UMWA | OTHER | 870545614MY1 | 01 | UT | EDUCATORS MUTUAL | OTHER | PR01114 | 01 | UT | MOLINA | OTHER | 833386 | 05 | AZ |   | MEDICAID | 002089140 | 05 | NV |   | MEDICAID |