Provider Demographics
NPI:1235439811
Name:TUCKER MEDICAL GROUP, P.C.
Entity Type:Organization
Organization Name:TUCKER MEDICAL GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-660-8687
Mailing Address - Street 1:PO BOX 14
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84011-0014
Mailing Address - Country:US
Mailing Address - Phone:801-660-8687
Mailing Address - Fax:866-332-8067
Practice Address - Street 1:460 W 2600 S
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-7716
Practice Address - Country:US
Practice Address - Phone:801-660-8687
Practice Address - Fax:866-332-8067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-28
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000073029Medicare UPIN