Provider Demographics
NPI:1255366696
Name:ROUNDY, MICHAEL S (PHYSICIAN SURGEON)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:ROUNDY
Suffix:
Gender:M
Credentials:PHYSICIAN SURGEON
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4908
Mailing Address - Country:US
Mailing Address - Phone:801-299-3781
Mailing Address - Fax:201-299-2416
Practice Address - Street 1:630 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4908
Practice Address - Country:US
Practice Address - Phone:801-299-3781
Practice Address - Fax:201-299-2416
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5349062 89052084P0800X
UT5349062-12052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
260022408OtherRAILROAD MEDICARE
UT876000308007Medicaid
000055266Medicare ID - Type Unspecified
I07352Medicare UPIN