Provider Demographics
NPI:1093923591
Name:UTAH LUNG CENTER, LLC
Entity Type:Organization
Organization Name:UTAH LUNG CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IMAD
Authorized Official - Middle Name:S
Authorized Official - Last Name:FARRUKH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-562-5864
Mailing Address - Street 1:PO BOX 150173
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84415
Mailing Address - Country:US
Mailing Address - Phone:801-479-0601
Mailing Address - Fax:801-479-4768
Practice Address - Street 1:3584 W 9000 S
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088
Practice Address - Country:US
Practice Address - Phone:801-562-5864
Practice Address - Fax:801-568-0202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT180183-1205207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Not Answered207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTE27987Medicare UPIN