Provider Demographics
NPI:1336406438
Name:ALLEGIS CARE-UTAH, PC
Entity Type:Organization
Organization Name:ALLEGIS CARE-UTAH, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DIRK
Authorized Official - Middle Name:O
Authorized Official - Last Name:WALES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-564-3511
Mailing Address - Street 1:1340 S DAMEN AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1169
Mailing Address - Country:US
Mailing Address - Phone:773-292-4800
Mailing Address - Fax:312-564-4059
Practice Address - Street 1:10808 SOUTH RIVER ROAD
Practice Address - Street 2:SUITE 344
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-6103
Practice Address - Country:US
Practice Address - Phone:773-292-4800
Practice Address - Fax:312-564-4059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-13
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207R00000X, 213E00000X
UT207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty