Provider Demographics
NPI:1710925631
Name:VAN BOERUM, DREW HOWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:DREW
Middle Name:HOWARD
Last Name:VAN BOERUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-314-4900
Mailing Address - Fax:801-314-4919
Practice Address - Street 1:5848 S 300 E
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6121
Practice Address - Country:US
Practice Address - Phone:801-314-4900
Practice Address - Fax:801-314-4919
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3641301205207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT942854057005Medicaid
UT005736206Medicare PIN
UT069014010Medicare PIN
UT000063571Medicare PIN
H58076Medicare UPIN
UT942854057005Medicaid
UT000062324Medicare PIN