Provider Demographics
NPI:1962439570
Name:GORDON PETTY GEORGE, MD, PC
Entity Type:Organization
Organization Name:GORDON PETTY GEORGE, MD, PC
Other - Org Name:INTERMOUNTAIN PAIN SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:P
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-431-0100
Mailing Address - Street 1:255 S ALPINE DR
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:UT
Mailing Address - Zip Code:84004-1748
Mailing Address - Country:US
Mailing Address - Phone:801-431-0100
Mailing Address - Fax:801-431-7354
Practice Address - Street 1:800 N 700 W
Practice Address - Street 2:STE 340A
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057
Practice Address - Country:US
Practice Address - Phone:801-431-0100
Practice Address - Fax:801-431-7354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT166871 1205207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty