Provider Demographics
NPI:1902185309
Name:SEVIER VALLEY MEDICAL CLINIC PLLC
Entity Type:Organization
Organization Name:SEVIER VALLEY MEDICAL CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLACKHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-529-4243
Mailing Address - Street 1:131 NORTH MAIN STREET
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SALINA
Mailing Address - State:UT
Mailing Address - Zip Code:84654-1107
Mailing Address - Country:US
Mailing Address - Phone:435-529-4243
Mailing Address - Fax:435-529-4239
Practice Address - Street 1:131 E MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:SALINA
Practice Address - State:UT
Practice Address - Zip Code:84654-1335
Practice Address - Country:US
Practice Address - Phone:435-529-4243
Practice Address - Fax:435-529-4239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3715201204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty