Basic Information
| Provider Information | |||||||||
| NPI: | 1972503696 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UTAH DIGESTIVE HEALTH INSTITUTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6028 S RIDGELINE DR | ||||||||
| Address2: | #201 | ||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844056914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014755400 | ||||||||
| FaxNumber: | 8014758614 | ||||||||
| Practice Location | |||||||||
| Address1: | 6028 S RIDGELINE DR | ||||||||
| Address2: | #201 | ||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844056914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014755400 | ||||||||
| FaxNumber: | 8014758614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2005 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 08/02/2005 | ||||||||
| NPIReactivationDate: | 08/24/2007 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LOWE | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8014755400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 48268889301001 | 01 | UT | REGENCE BLUE CROSS | OTHER | 107006015101 | 01 | UT | IHC | OTHER |