Provider Demographics
NPI:1669652343
Name:SHELLY SAVAGE M D LLC
Entity Type:Organization
Organization Name:SHELLY SAVAGE M D LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SAVAGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-373-2001
Mailing Address - Street 1:1900 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1341
Mailing Address - Country:US
Mailing Address - Phone:801-373-2001
Mailing Address - Fax:801-373-4748
Practice Address - Street 1:1900 N STATE ST
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-1341
Practice Address - Country:US
Practice Address - Phone:801-373-2001
Practice Address - Fax:801-373-4748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4775407-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTH31113Medicare UPIN
UT000055978Medicare PIN