Provider Demographics
NPI:1366624991
Name:NATHAN G MOMBERGER MD PC
Entity Type:Organization
Organization Name:NATHAN G MOMBERGER MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GENE
Authorized Official - Middle Name:R
Authorized Official - Last Name:OAKES
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:801-314-5026
Mailing Address - Street 1:5848 FASHION BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6121
Mailing Address - Country:US
Mailing Address - Phone:801-314-5026
Mailing Address - Fax:801-314-4015
Practice Address - Street 1:5848 FASHION BLVD STE 110
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-6121
Practice Address - Country:US
Practice Address - Phone:801-314-5026
Practice Address - Fax:801-314-4015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3208681205207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528299949009Medicaid
UTH22841Medicare UPIN
UT000057216Medicare PIN