Provider Demographics
NPI:1629034855
Name:NORTHERN UTAH GASTROENTEROLOGY AND ENDOSCOPY SPECIALISTS LLC
Entity Type:Organization
Organization Name:NORTHERN UTAH GASTROENTEROLOGY AND ENDOSCOPY SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DIRK
Authorized Official - Middle Name:R
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-792-6105
Mailing Address - Street 1:630 E 1400 N
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2534
Mailing Address - Country:US
Mailing Address - Phone:435-787-0270
Mailing Address - Fax:435-787-0262
Practice Address - Street 1:630 E 1400 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2534
Practice Address - Country:US
Practice Address - Phone:435-787-0270
Practice Address - Fax:435-787-0262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000055668Medicare ID - Type Unspecified
UT005566803Medicare PIN
UT005566802Medicare PIN
UT005566801Medicare PIN