Provider Demographics
NPI:1679691398
Name:HEART OF DIXIE PC
Entity Type:Organization
Organization Name:HEART OF DIXIE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:BOORMAN
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:435-251-2900
Mailing Address - Street 1:1380 E MEDICAL CENTER DR
Mailing Address - Street 2:STE # 4100
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-2156
Mailing Address - Country:US
Mailing Address - Phone:435-251-2900
Mailing Address - Fax:435-251-2901
Practice Address - Street 1:1380 E MEDICAL CENTER DR
Practice Address - Street 2:STE # 4100
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2156
Practice Address - Country:US
Practice Address - Phone:435-251-2900
Practice Address - Fax:435-251-2901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1846891205207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000060943Medicare PIN