Provider Demographics
NPI:1124298377
Name:WASATCH PHYSICAL AND REHABILITATION MEDICINE, P.C.
Entity type:Organization
Organization Name:WASATCH PHYSICAL AND REHABILITATION MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:R
Authorized Official - Last Name:MELVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-732-5900
Mailing Address - Street 1:4403 HARRISON BLVD STE 1875
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-3325
Mailing Address - Country:US
Mailing Address - Phone:801-732-5900
Mailing Address - Fax:801-732-7989
Practice Address - Street 1:4403 HARRISON BLVD STE 1875
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3325
Practice Address - Country:US
Practice Address - Phone:801-732-5900
Practice Address - Fax:801-732-5989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT400823741000Medicaid
UT000004812Medicare PIN
UT400823741000Medicaid