Provider Demographics
NPI:1851320907
Name:HTIPHYSICIAN SERVICES BUSINESS OFFICE
Entity Type:Organization
Organization Name:HTIPHYSICIAN SERVICES BUSINESS OFFICE
Other - Org Name:SOUTH OGDEN CENTER FOR FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SUMMERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-479-7771
Mailing Address - Street 1:5740 CRESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-4869
Mailing Address - Country:US
Mailing Address - Phone:801-479-7771
Mailing Address - Fax:801-479-7795
Practice Address - Street 1:5740 CRESTWOOD DR
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-4869
Practice Address - Country:US
Practice Address - Phone:801-479-7771
Practice Address - Fax:801-479-7795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========006Medicaid