Provider Demographics
NPI:1760814834
Name:SANDMAN PHYSICIAN SERVICES PC
Entity Type:Organization
Organization Name:SANDMAN PHYSICIAN SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:GLINES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-209-7348
Mailing Address - Street 1:637 SEGO LILY CIR
Mailing Address - Street 2:
Mailing Address - City:NORTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-3355
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:637 SEGO LILY CIR
Practice Address - Street 2:
Practice Address - City:NORTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84054-3355
Practice Address - Country:US
Practice Address - Phone:801-209-7348
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT75964441205207L00000X, 207LH0002X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207LH0002XAllopathic & Osteopathic PhysiciansAnesthesiologyHospice and Palliative MedicineGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty