Provider Demographics
NPI:1558573881
Name:BRIGHAM CITY ORTHOPEDIC CLINIC PC
Entity Type:Organization
Organization Name:BRIGHAM CITY ORTHOPEDIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEWEY
Authorized Official - Middle Name:C
Authorized Official - Last Name:MACKAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-723-1747
Mailing Address - Street 1:PO BOX 883
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-0883
Mailing Address - Country:US
Mailing Address - Phone:435-723-1747
Mailing Address - Fax:435-723-6851
Practice Address - Street 1:950 MEDICAL DR
Practice Address - Street 2:SUITE 106
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-4724
Practice Address - Country:US
Practice Address - Phone:435-723-1747
Practice Address - Fax:435-723-6851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT160581-1205207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTC18653Medicare UPIN