Provider Demographics
NPI:1619048170
Name:EASTERN UTAH SURGICAL CENTER
Entity Type:Organization
Organization Name:EASTERN UTAH SURGICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:E
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-637-1744
Mailing Address - Street 1:200 N FAIRGROUNDS RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-4205
Mailing Address - Country:US
Mailing Address - Phone:435-637-1744
Mailing Address - Fax:435-637-1123
Practice Address - Street 1:200 N FAIRGROUNDS RD
Practice Address - Street 2:SUITE 1
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-4205
Practice Address - Country:US
Practice Address - Phone:435-637-1744
Practice Address - Fax:435-637-1123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5249970-1704261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT20034276600001OtherBCBS PROVIDER NUMBER
UT20034276600001OtherBCBS PROVIDER NUMBER
UT000100075Medicare PIN