Provider Demographics
NPI:1932118171
Name:BERGQUIST, BARRY DALE (MD)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:DALE
Last Name:BERGQUIST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 NORTH CENTER ST #800
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-7406
Mailing Address - Country:US
Mailing Address - Phone:801-990-1911
Mailing Address - Fax:801-990-1912
Practice Address - Street 1:5121 S COTTONWOOD STREET
Practice Address - Street 2:INTERMOUNTAIN MEDICAL CENTER
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84157
Practice Address - Country:US
Practice Address - Phone:801-507-5248
Practice Address - Fax:801-733-5618
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT93-188635-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002086426Medicaid
UT1502954OtherUMWA
UT8597445OtherWORKERS COMP FUND
UT870545614BE1OtherEDUCATORS MUTUAL
UTPRA04665OtherMOLINA
UT2090168OtherUNITED HEALTHCARE
UT96764OtherDESERET MUTUAL
ID003575200Medicaid
UT107005508101OtherIHC
WY110405500Medicaid
AZ182949Medicaid
UT53226OtherHEALTHY U
UT37773OtherPEHP
UTQM0000075886OtherALTIUS
UTQM0000075886OtherALTIUS
NV002086426Medicaid
UT005532704Medicare ID - Type Unspecified