Provider Demographics
NPI:1689788762
Name:UTAH PAIN & REHAB INC.
Entity Type:Organization
Organization Name:UTAH PAIN & REHAB INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:WAHLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-337-4000
Mailing Address - Street 1:1276 WALL AVE
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84404-5657
Mailing Address - Country:US
Mailing Address - Phone:801-337-4000
Mailing Address - Fax:801-337-4002
Practice Address - Street 1:1276 WALL AVE
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404-5657
Practice Address - Country:US
Practice Address - Phone:801-337-4000
Practice Address - Fax:801-337-4002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT346009-1202111N00000X
UT273153-1202111N00000X
UT58673691205207LP2900X
UT77062171205207LP2900X
UT537865-12052081P2900X
UT347196-4405363L00000X
UT223876-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000057143Medicare ID - Type Unspecified