Provider Demographics
NPI:1972759371
Name:REBECCA LEVINE, MD, PLLC
Entity Type:Organization
Organization Name:REBECCA LEVINE, MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / MD
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-569-9119
Mailing Address - Street 1:PO BOX 413008
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84141-0001
Mailing Address - Country:US
Mailing Address - Phone:801-569-9119
Mailing Address - Fax:801-569-9103
Practice Address - Street 1:1575 W 7000 S
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-3431
Practice Address - Country:US
Practice Address - Phone:801-569-9113
Practice Address - Fax:801-569-9103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT33292020-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1972759371OtherCORP NPI
UT1316986136OtherINDIVIDUAL NPI
UT=========OtherTAX ID NUMBER
UTH40521Medicare UPIN