Provider Demographics
NPI:1760664668
Name:DR LORELL FAWSON DPM
Entity Type:Organization
Organization Name:DR LORELL FAWSON DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:KERSKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-627-2122
Mailing Address - Street 1:3590 HARRISON BLVD SUITE G-1
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403
Mailing Address - Country:US
Mailing Address - Phone:801-627-2122
Mailing Address - Fax:801-627-2125
Practice Address - Street 1:3590 HARRISON BLVD
Practice Address - Street 2:SUITE G1
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-2060
Practice Address - Country:US
Practice Address - Phone:801-627-2122
Practice Address - Fax:801-627-2125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTT77940Medicare UPIN
UT5240980001Medicare NSC
UT000055975Medicare PIN
UT000057442Medicare PIN
UT000057443Medicare PIN