Provider Demographics
NPI:1346255098
Name:R C HALVERSEN MD PC
Entity Type:Organization
Organization Name:R C HALVERSEN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MGR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-577-7055
Mailing Address - Street 1:1160 E 3900 S
Mailing Address - Street 2:4100
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124
Mailing Address - Country:US
Mailing Address - Phone:801-268-3800
Mailing Address - Fax:801-268-3997
Practice Address - Street 1:1160 E 3900 S
Practice Address - Street 2:4100
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124
Practice Address - Country:US
Practice Address - Phone:801-268-3800
Practice Address - Fax:801-268-3997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD99448Medicare UPIN