Provider Demographics
NPI:1083998603
Name:OGDEN INTERNAL MEDICINE AND UROLOGY
Entity Type:Organization
Organization Name:OGDEN INTERNAL MEDICINE AND UROLOGY
Other - Org Name:LAYTON FAMILY SPECIALITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:
Authorized Official - Last Name:KANE
Authorized Official - Suffix:
Authorized Official - Credentials:VP
Authorized Official - Phone:801-568-5960
Mailing Address - Street 1:2950 N CHURCH STREET
Mailing Address - Street 2:301
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84040
Mailing Address - Country:US
Mailing Address - Phone:801-547-0747
Mailing Address - Fax:
Practice Address - Street 1:2950 N CHURCH STREET
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84040
Practice Address - Country:US
Practice Address - Phone:801-546-9441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1003001553Medicaid
UTDH0022Medicare PIN