Provider Demographics
NPI:1407804248
Name:OLD FARM OBSTETRICS & GYNECOLOGY
Entity Type:Organization
Organization Name:OLD FARM OBSTETRICS & GYNECOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRYANT
Authorized Official - Middle Name:J
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-261-3975
Mailing Address - Street 1:3970 S 700 E
Mailing Address - Street 2:SUITE 14
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2191
Mailing Address - Country:US
Mailing Address - Phone:801-261-3975
Mailing Address - Fax:801-265-8035
Practice Address - Street 1:3970 S 700 E
Practice Address - Street 2:SUITE 14
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-2191
Practice Address - Country:US
Practice Address - Phone:801-261-3975
Practice Address - Fax:801-265-8035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty