Provider Demographics
NPI:1285664078
Name:CHAMBERLAIN, BRUCE H (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:H
Last Name:CHAMBERLAIN
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 1:1121 E 3900 S STE C230
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1297
Mailing Address - Country:US
Mailing Address - Phone:801-262-9494
Mailing Address - Fax:
Practice Address - Street 1:5131 S COTTONWOOD ST # L-2
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5701
Practice Address - Country:US
Practice Address - Phone:801-263-3416
Practice Address - Fax:801-263-3428
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-45115207RH0002X
UT281942-1205208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000109211OtherMEDICARE UT PTAN
UT1285664078Medicaid