Provider Demographics
NPI:1487687430
Name:INTERMOUNTAIN SKIN CANCER & ESTHETICS CENTER PC
Entity Type:Organization
Organization Name:INTERMOUNTAIN SKIN CANCER & ESTHETICS CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:EDGAR
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-627-0515
Mailing Address - Street 1:3860 JACKSON AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-1956
Mailing Address - Country:US
Mailing Address - Phone:801-627-0515
Mailing Address - Fax:801-627-0517
Practice Address - Street 1:3860 JACKSON AVE STE 2
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-1997
Practice Address - Country:US
Practice Address - Phone:801-627-0515
Practice Address - Fax:801-627-0517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT159426-1205174400000X
UT5316026-1205174400000X
UT323171-1206174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTH87350Medicare UPIN
UTD20153Medicare UPIN
UTR65216Medicare UPIN
UT000012067Medicare ID - Type Unspecified
UT000005364Medicare ID - Type Unspecified
UT005731501Medicare ID - Type Unspecified