Provider Demographics
NPI:1851545081
Name:PREMIER PLASTIC SURGERY GROUP OF UTAH, LLC
Entity Type:Organization
Organization Name:PREMIER PLASTIC SURGERY GROUP OF UTAH, LLC
Other - Org Name:PPSG-BOUNTIFUL
Other - Org Type:Other Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:KJAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-295-9105
Mailing Address - Street 1:1551 RENAISSANCE TOWNE DR
Mailing Address - Street 2:SUITE 360
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-7675
Mailing Address - Country:US
Mailing Address - Phone:801-295-9105
Mailing Address - Fax:801-295-9264
Practice Address - Street 1:1551 RENAISSANCE TOWNE DR
Practice Address - Street 2:SUITE 360
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-7675
Practice Address - Country:US
Practice Address - Phone:801-295-9105
Practice Address - Fax:801-295-9264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-14
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT170345-1205208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTC63628Medicare UPIN