Provider Demographics
NPI:1033209622
Name:BURT, RANDALL W (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:W
Last Name:BURT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 581700
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84158-1700
Mailing Address - Country:US
Mailing Address - Phone:801-213-3800
Mailing Address - Fax:
Practice Address - Street 1:HUNTSMAN CANCER INSTITUTE
Practice Address - Street 2:2000 CIRCLE OF HOPE
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112
Practice Address - Country:US
Practice Address - Phone:801-585-3281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT160757-1205207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT87-0446925001Medicaid
UT87-0446925001Medicaid
UTD20159Medicare UPIN