Provider Demographics
NPI:1407956121
Name:BARTHOLOMEW, BRYAN R (DO)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:R
Last Name:BARTHOLOMEW
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1468
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84011-1468
Mailing Address - Country:US
Mailing Address - Phone:801-299-7800
Mailing Address - Fax:
Practice Address - Street 1:520 MEDICAL DR STE 200
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010
Practice Address - Country:US
Practice Address - Phone:801-299-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT308222-1204207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD6955Medicaid
UTP00807099OtherRAILROAD MEDICARE
UTP00364520Medicare PIN
UT000068727Medicare PIN
UTP00807099OtherRAILROAD MEDICARE
I65193Medicare UPIN