Provider Demographics
NPI:1366653230
Name:MARLIN M FORSYTH
Entity Type:Organization
Organization Name:MARLIN M FORSYTH
Other - Org Name:BOUNTIFUL PHYSICAL THERAPY-SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARLIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:FORSYTH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:801-292-5011
Mailing Address - Street 1:425 MEDICAL DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4945
Mailing Address - Country:US
Mailing Address - Phone:801-292-5011
Mailing Address - Fax:801-292-8222
Practice Address - Street 1:425 MEDICAL DR
Practice Address - Street 2:SUITE 104
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4945
Practice Address - Country:US
Practice Address - Phone:801-292-5011
Practice Address - Fax:801-292-8222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005700804Medicare ID - Type Unspecified
UT005700803Medicare ID - Type Unspecified
UT005700801Medicare ID - Type Unspecified