Provider Demographics
NPI:1467581173
Name:TOOELE ORTHOPEDICS & SPORTS MEDICINE SPECIALISTS
Entity Type:Organization
Organization Name:TOOELE ORTHOPEDICS & SPORTS MEDICINE SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-833-9180
Mailing Address - Street 1:2356 N 400 E
Mailing Address - Street 2:STE 102
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-3409
Mailing Address - Country:US
Mailing Address - Phone:435-833-9180
Mailing Address - Fax:435-833-9177
Practice Address - Street 1:2356 N 400 E
Practice Address - Street 2:STE 102
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-3409
Practice Address - Country:US
Practice Address - Phone:435-833-9180
Practice Address - Fax:435-833-9177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5617074-1204207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD5620Medicaid
UTD5620Medicaid
UT6038310001Medicare NSC