Provider Demographics
NPI:1205957131
Name:HUNTER MEDICAL CENTER, INC
Entity type:Organization
Organization Name:HUNTER MEDICAL CENTER, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERIC
Authorized Official - Middle Name:M
Authorized Official - Last Name:CIVISH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-282-2677
Mailing Address - Street 1:3354 W 7800 S
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-4506
Mailing Address - Country:US
Mailing Address - Phone:801-282-2677
Mailing Address - Fax:801-282-2050
Practice Address - Street 1:3354 W 7800 S
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-4506
Practice Address - Country:US
Practice Address - Phone:801-282-2677
Practice Address - Fax:801-282-2050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT184916-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000055875Medicare ID - Type UnspecifiedGROUP NUMBER