Provider Demographics
NPI:1558690610
Name:JOSEPH D HILLAM MD A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:JOSEPH D HILLAM MD A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:D
Authorized Official - Last Name:HILLAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-734-9439
Mailing Address - Street 1:990 MEDICAL DRIVE
Mailing Address - Street 2:SUITE U2
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-4714
Mailing Address - Country:US
Mailing Address - Phone:435-734-9439
Mailing Address - Fax:435-723-0267
Practice Address - Street 1:990 MEDICAL DR
Practice Address - Street 2:SUITE U2
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-4713
Practice Address - Country:US
Practice Address - Phone:435-734-9439
Practice Address - Fax:435-723-0267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-18
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1529431205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528620884009Medicaid
UT528620884009Medicaid