Provider Demographics
NPI:1922119528
Name:BRIGHAM MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:BRIGHAM MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKAMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-734-2041
Mailing Address - Street 1:PO BOX 719
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-0719
Mailing Address - Country:US
Mailing Address - Phone:435-734-2041
Mailing Address - Fax:435-723-8028
Practice Address - Street 1:600 W HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-3006
Practice Address - Country:US
Practice Address - Phone:435-734-2041
Practice Address - Fax:435-723-8028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT175715-1205207Q00000X
UT151481-1205207Q00000X
UT151559-1205207Q00000X
UT160903-1205207Q00000X
UT163362-1205207R00000X
UT185588-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========011Medicaid
UT1021610001Medicare NSC